Remote Claims Research & Resolution Specialist

Humana; South Carolina; 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

Parental and caregiver leave

Job summary

Humana is hiring a Claims Research & Resolution Representative 3 to manage complex medical claim investigations and settlements. You will work with providers, members, and teams to ensure accurate resolution and compliance, reporting to the Supervisor, Claims & Research Resolution.

The role starts with 8 weeks of virtual training, Mon–Fri, 8:00am–4:30pm EST, then shifts to 6:00am–5:30pm EST, Monday–Friday. Travel to Humana offices may be required occasionally.

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.
• Healthcare call center experience.
• Medical claims processing experience.
• Member reimbursement experience.
• Medicare industry.
• Healthcare Benefit knowledge.

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

Excel

Word

Medicare/Medicaid claims

Healthcare terminology

Tools

Microsoft Access

Job description

Humana is hiring a Claims Research & Resolution Representative 3 to manage complex medical claim investigations and settlements. You will work with providers, members, and teams to ensure accurate resolution and compliance, reporting to the Supervisor, Claims & Research Resolution.

The role starts with 8 weeks of virtual training, Mon–Fri, 8:00am–4:30pm EST, then shifts to 6:00am–5:30pm EST, Monday–Friday. Travel to Humana offices may be required occasionally.