Claims Research Resolution Rep

Humana; Georgia; Remote; USD 43,000 - 56,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Job summary

Humana's Claims Research & Resolution Representative 3 role focuses on managing claims operations, including customer contact, investigation, and settlement. You will report to the Supervisor, Claims & Research Resolution.

Training consists of virtual sessions for 8 weeks, Monday–Friday, 8:00am–4:30pm EST. After training, you will work Monday–Friday, 6:00am–5:30pm EST, with an 18-month commitment to the team.

Qualifications

• 1+ years of healthcare customer service experience.
• 1+ years of call center experience.
• Intermediate Excel skills.
• Intermediate proficiency Word.
• Working knowledge of healthcare terminology.
• Working knowledge of Medicare or Medicaid claims.

Responsibilities

• Work with providers, members, and third-party collection services to facilitate timely and accurate resolution of complex medical claims.
• Investigate discrepancies, verify documentation, and ensure compliance with internal policies and regulatory standards.
• Collaborate with claims, call center, and provider teams to research pending claims issues.
• Apply advanced judgment to determine methods, strategies, and workflows for managing administrative tasks and projects.
• Demonstrate autonomy, using experience and knowledge to resolve claims inquiries.
• Pivot between projects based on business needs and handle support requests from various channels.

Skills

Healthcare customer service

Call center experience

Medicare/Medicaid claims knowledge

Healthcare terminology

Tools

Excel

Word

Microsoft Access

Job description

Become a part of our caring community

The Claims Research & Resolution Representative 3 manages claims operations that involve customer contact, investigation, and settlement of claims for and against our organization. You will report the Supervisor, Claims & Research Resolution.

As the Claims Research & Resolution Representative 3 you will

• Work with providers, members, and third-party collection services to facilitate timely and accurate resolution of complex medical claims.
• Use in-depth knowledge of claims processes to investigate discrepancies, verify documentation, and ensure compliance with internal policies and regulatory standards.
• Collaborate with specialized team of claims, call center, and provider associates to research pending claims issues.
• Apply advanced judgment and discretion in determining appropriate methods, strategies, and workflows for managing administrative tasks and projects.
• Demonstrate a high level of autonomy, applying experience and organizational knowledge to resolve claims inquiries.
• Pivot quickly from one project to the next, based on business needs, with the ability to experience handling support requests from a variety of different channels, based on inventory load

Required Qualifications

• 1 or more years of Healthcare customer service experience
• 1 or more years of call center experience
• Intermediate Excel skills
• Intermediate proficiency Word
• Working knowledge of healthcare terminology
• Working knowledge of Medicare or Medicaid claims

Preferred Qualifications

• Healthcare call center experience
• Working knowledge with Microsoft AccessMedical claims processing experience
• Member reimbursement experience
• Medicare industry
• Healthcare Benefit knowledge

Required Work Schedule

Training you will:

• Virtual training and runs for 8 weeks with a schedule of Monday – Friday, 8:00am – 4:30pm EST.
• Attendance is vital for success; other than Humana-observed holidays, no time off is allowed during training or during your first 120 days of employment.
• You must be on time, dressed appropriately, with your camera ON for the entire duration of training, nesting, and for other meetings required by leadership.

After Training You Will

• Following training, you must be able to work any shift Monday – Friday, between the hours of 6:00am – 5:30pm EST.
• You will learn many systems, policies, and tools, and it takes times to become proficient in the role. You must be willing to remain in this position for a period of eighteen (18) months before applying to other Humana opportunities outside of this team.
• Requires an 18 month time in job commitment

Work at Home Requirements:

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$43,000 - $56,200 per year

Description Of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.