Remote Claims Research & Resolution Specialist

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

Job summary

Humana is seeking a Claims Research & Resolution Representative 3 to manage complex medical claims, including investigation, provider/member coordination, and settlement processes. This role reports to the Supervisor, Claims & Research Resolution and supports multiple teams to ensure accurate resolutions.

Key duties include analyzing claim discrepancies, ensuring regulatory compliance, and maintaining high service quality across channels.

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.
• Investigation of discrepancies, verify documentation, and ensure compliance with internal policies and regulatory standards.
• Collaborate with a team of claims, call center, and provider associates to research pending claims issues.
• Apply advanced judgment and discretion in determining methods, strategies, and workflows for managing administrative tasks and projects.

Skills

Healthcare CS

Call center

Excel

Word

Healthcare terminology

Medicare/Medicaid claims

Tools

Microsoft Access

Job description

Humana is seeking a Claims Research & Resolution Representative 3 to manage complex medical claims, including investigation, provider/member coordination, and settlement processes. This role reports to the Supervisor, Claims & Research Resolution and supports multiple teams to ensure accurate resolutions.

Key duties include analyzing claim discrepancies, ensuring regulatory compliance, and maintaining high service quality across channels.