Remote Claims Research & Resolution Specialist

Humana; Rhode Island; Remote; USD 43,000 - 56,000; Full time

Job summary

Humana is looking for a Claims Research & Resolution Representative 3 to manage complex medical claims involving customer contact, investigation, and settlement. You will report to the Supervisor, Claims & Research Resolution, and collaborate with providers, members, and third-party services to ensure accurate and timely outcomes.

This remote role includes training, a 40-hour week, and the opportunity to work across multiple systems and policies, with dual emphasis on autonomy and procedural

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.
• 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

Skills

Healthcare customer service

Call center experience

Excel

Word

Healthcare terminology

Medicare/Medicaid claims

Tools

Microsoft Access

Job description

Humana is looking for a Claims Research & Resolution Representative 3 to manage complex medical claims involving customer contact, investigation, and settlement. You will report to the Supervisor, Claims & Research Resolution, and collaborate with providers, members, and third-party services to ensure accurate and timely outcomes.

This remote role includes training, a 40-hour week, and the opportunity to work across multiple systems and policies, with dual emphasis on autonomy and procedural