Claims Research and Resolution Professional 2

Become a part of our caring community and help us put health first

The Provider Claims Educator reports to the Claims Education Manager and is responsible for tracking and trending claims data and completing root cause analyses of claims denials or rework, underpayments, and claims errors. This role educates providers, one-on-one or in group settings, on appropriate claims submission processes and requirements, coding updates, and common billing errors to reduce claims denials and support accurate and timely provider payment. This position works assignments that are varied and frequently require interpretation and independent determination of the appropriate courses of action. The individual in this role understands department, segment, and organizational strategy and operating objectives, including their applications to assignments. The Claims Educator follows general guidance and processes and must use independent judgement to execute effectively on assigned work.

Key Role Objectives

• Routinely track provider claims data for providers in the Virginia Medicaid network to identify trends in denials and rework
• Analyze claims denial and rework root causes to support determination of appropriate intervention
• Conduct provider training (one-on-one or multi-provider) on claims denials, rework, and/or underpayments based on trended provider claims issues and common claims errors
• Monitor providers post-training to ensure claim denial root causes are resolved
• Escalate any trended claims issues stemming from internal systems issues to Provider Claims Manager and support development of systems issue resolution
• Convene billing forums with selected provider associations to share billing guidance and answer provider questions
• Partner with Provider Relations Representatives to ensure prompt resolution of provider inquiries, concerns, or problems associated with claims payment
• Assist with development of provider bulletins or training documents related to common claims issues and billing inaccuracies
• Partner with internal corporate teams to ensure effective cross-department communication and prompt, accurate resolution to provider issues
  
  

Required Qualifications

Use your skills to make an impact

• 2+ years of health insurance claims experience
• Experience working for or with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers)
• Experience analyzing data to track and trend common claims issues
• Self-starter and resourceful in order to solve problems of varying complexities
• Excellent written and verbal communication skills
• Exceptional time management and ability to manage multiple priorities in a fast-paced environment
• Knowledge of Microsoft Office applications
• Must reside in Virginia. Position is remote with the ability to work in the Glen Allen Humana office
  
  

Preferred Qualifications

• Bachelor's degree
• Experience with Virginia Medicaid
• Thorough understanding of managed care contracts, including contract language and reimbursement
• Experience with claims systems, adjudication, submission processes, coding, and/or dispute resolution
  
  

Work at Home Criteria

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 recommended; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• 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.

$59,300 - $80,900 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About Us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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.

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.