Claims Research & Resolution Representative

Humana; North Carolina; On-site; USD 40,000 - 52,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off

Job summary

Humana is seeking a Claims Research & Resolution Representative 2 to manage claims operations involving customer contact, investigation, and resolution of claims or related financial issues. This remote role supports a Fortune 100 company with a strong culture and benefits.

You will handle inbound calls, document inquiries, possibly outbound follow-ups, and work with multiple systems including Mentor. Training lasts 8 weeks; a 12-month commitment is expected; typical schedule is 40 hours weekly

Qualifications

• 1+ years of call center or telephonic customer service experience (within the past 5 years).
• Previous healthcare related experience or education.
• Basic Microsoft Office (Word, Excel, Outlook, and Teams) skills.
• Strong technical skills across multiple software systems.
• Ability to work independently under minimum supervision.
• Ability to use internal resources (Mentor) to resolve inquiries.
• Strong time management and prioritization skills.
• Experience managing multiple or competing priorities.
• Capacity to maintain confidentiality while working remotely.

Responsibilities

• Take inbound calls to address customer needs including complex financial recovery and inquiries.
• Potentially make outbound calls for case follow-up.
• Record notes with details of inquiries, comments or complaints and take action accordingly.
• Escalate unresolved and pending customer inquiries.
• Make decisions within area policy and methods for completing assignments.
• Work within defined parameters with some latitude over prioritization and timing.
• Cross-train in all functions within the department.

Skills

Call Center

Healthcare experience

Microsoft Office

Multisystem usage

Time management

Confidentiality

Independent work

Education

Bachelor's Degree

Tools

Mentor

Job description

Become a part of our caring community
The Claims Research & Resolution Representative 2 manages claims operations that involve customer contact, investigation, and resolution of claims or claims-related financial issues. The position includes moderately complex call center, administrative, operational and customer support assignments. Workload is typically semi-routine assignments along with intermediate level math computations. This is an opportunity to work remotely and use your research, resolution and customer service skills to join a Fortune 100 company with a great culture and outstanding benefits. Humana values associate engagement and well-being. We also provide excellent professional development and continued education.

Become a part of our caring community
The Claims Research & Resolution Representative 2 manages claims operations that involve customer contact, investigation, and resolution of claims or claims-related financial issues. The position includes moderately complex call center, administrative, operational and customer support assignments. Workload is typically semi-routine assignments along with intermediate level math computations. This is an opportunity to work remotely and use your research, resolution and customer service skills to join a Fortune 100 company with a great culture and outstanding benefits. Humana values associate engagement and well-being. We also provide excellent professional development and continued education.

Responsibilities

The Claims inbound call center is comprised of a group of calls / claims / provider associates researching the resolution to a pending call.

• You will take inbound calls to address customer needs which may include complex financial recovery, answering questions, and resolving issues.
• You will potentially be making outbound calls regarding case follow-up.
• You will record notes with details of inquiries, comments or complaints, transactions or interactions and taking action accordingly.
• You will escalte unresolved and pending customer inquiries.
• Decisions you make in this role are typically focused on interpretation of area or department policy and methods for completing assignments.
• Our standard policies and practices allow for some opportunity for interpretation / deviation and / or independent discretion. You will work within defined parameters to identify work expectations and quality standards, but you will have some latitude over prioritization and timing, and will work with minimal direction.
• You will cross-train in all functions within the department.

Required Qualifications

Use your skills to make an impact

• One (1) or more years of Call Center or Telephonic customer service experience (within the past 5 years)
• Previous healthcare related experience or education
• Basic Microsoft Office (Word, Excel, Outlook, and Teams) skills
• You must have strong technical skills with the ability to work across multiple software systems
• You must be self-reliant, with the ability to resolve issues independently under minimum supervision
• You must have the ability to use internal system resources (i.e., Mentor) to find a resolution to an issue and / or respond to an inquiry
• You must have demonstrated time management and prioritization skills
• You must have experience managing multiple or competing priorities
• Requires that you have the capacity to maintain confidentiality while working remotely out of your home

Required Work Schedule

Training

• Virtual training starts on day one of employment and will run up to 8 weeks with a schedule of 8:00 AM to 4:30 PM Eastern Time, Monday - Friday.
• Attendance is vital for your success; no time off will be allowed during training.
• The initial 180 days of employment as a Claims Research & Resolution Representative 2 constitute an appraisal period. This Appraisal Period is essential to your learning and development, which is why we ask for perfect attendance during both the classroom training and nesting periods.
• This position requires learning many systems, policies, and tools, and it takes time to become proficient in the role. You must be willing to remain in this position for a period of twelve (12) months before applying to other Humana opportunities.

Work Hours

• Following training, you must be able to work an assigned 8-hour shift between the hours of 8:00 AM to 6:00 PM Eastern Time.
• Overtime may be offered, based on business needs.

Preferred Qualifications

• Bachelor's Degree
• Prior claims processing experience
• Overpayment experience
• Financial recovery experience
• Previous experience with Mentor software
• PrePay or Post Pay experienceCAS, CIS or CISPRO experience
• CRM experience

Additional Information

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.

$40,000 - $52,300 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.

Application Deadline: 08-31-2026

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.