Claims Research & Resolution Representative

Humana Inc; Puerto Rico; Hybrid; USD 34,000 - 45,000; 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 Inc. is seeking a Claims Research & Resolution Representative to join its Puerto Rico team. You will work with providers, members, and third-party services to resolve complex medical claims, verify documentation, and ensure compliance with policies and regulatory standards.

The role offers remote work with occasional travel to Humana offices for training; requires English fluency and Puerto Rico residency, with a 9-month probation and 18-month tenure window. Training starts December 2026.

Qualifications

• Must reside in Puerto Rico.
• 1+ years of claims or customer service experience.
• Must be able to communicate effectively in English, including speaking, reading, and writing, and pass a language proficiency assessment.

Responsibilities

• 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 to resolve claims inquiries.
• Use your skills to make an impact

Skills

English Proficiency

Claims Experience

Healthcare Terminology

Job description

Become a part of our caring community Join Humana's dynamic Puerto Rico team as a Claims Research & Resolution Representative and make a meaningful impact every day! You'll be at the heart of our claims operations—connecting with providers and members to resolve and settle claims that shape the health industry. You'll use your expertise to investigate cases, approve settlements, and navigate complex administrative challenges. If you thrive in a fast-paced environment and enjoy making decisions that matter, Humana invites you to bring your initiative and experience to our mission-driven team.

As a 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 to resolve claims inquiries.
• Use your skills to make an impact

Required Qualifications

• MUST currently reside in Puerto Rico
• 1+ years of claims OR customer service experience.
• Must be able to communicate effectively in English, including speaking, reading, and writing, to perform the essential functions of the role.
• Final selected candidates will be required to complete a language proficiency assessment.

Preferred Qualifications

• Knowledge of healthcare terminology
• Prior claims processing experience

Required Training Schedule:

Virtual training begins in December 2026 and will last for approximately 8 weeks. Training will be held Monday through Friday, 8:00 am – 5:00 pm, Eastern Time. Attendance is vital for success; no time off is allowed during training or the first 120 days.

Required Work Schedule:

Following training and a post-training support period, you must be able to work Monday through Friday between 6:00 am and 5:30 pm Eastern. Hours are subject to change based on business needs. This position incudes a 9-month probationary period. During which you and the manager assess how well you meet the requirements of the new position and work with our organization. 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 eighteen (18) months before applying to other Humana opportunities.

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. $34,400 - $45,000 per year

Description of Benefits

• 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 at Humana.com and at CenterWell.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.