Claims Research & Resolution Lead

at  Humana

BECOME A PART OF OUR CARING COMMUNITY AND HELP US PUT HEALTH FIRST

Humana Healthy Horizons in Virginia is seeking a Claims Research & Resolution Lead who will manage claims operations in the Virginia Medicaid market. They will manage and provide administration of provider claims issues related to Humana’s provider network. The Claims Research & Resolution Lead will manage objectives and determines approach, resources and goals.

USE YOUR SKILLS TO MAKE AN IMPACT

Required Requirements:

• Bachelor’s degree.
• 5+ years experience with claims systems, adjudication, submission processes, coding, dispute resolution, and/or other related function.
• 2+ years of progressive leadership experience.
• Experience reviewing and analyzing large sets of claims data.
• Proficiency in analyzing, understanding, and communicating complex issues.
• Knowledge of Microsoft Office applications.
• Strong business acumen, including technical knowledge of claims system and of authorization systems.
• Strong interpersonal, communication, and presentation skills.
• Ability to effectively interact with all levels of internal and external business partners.
• Ability to work independently as well as in a team and to manage time and resources to accomplish multiple tasks and meet deadlines.
• Knowledge of regulatory issues and of the impact on claims decisions.
• Ability to resolve claim issues and determine proper course of action and to efficiently access and navigate multiple claims systems.
• Must reside in Virginia with the ability to attend occasional meetings in Glen Allen location.

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.

• Oversees program activities and services related to claims administration.
• Requires cross departmental collaboration and conducts briefings and area meetings; maintains frequent contact with other leaders across the program.
• Works toward the resolution of claims, files, systems issues, and complaints.
• Ensures the claims handling process and communication complies with the Virginia Department of Medical Assistance (DMAS) regulations and Humana’s established procedures and policies.
• Performs root cause and audits of claims projects to determine trends and subsequently make recommendations for actions.
• Creates innovative solutions to automate processes and to build reports, dashboards, and metrics to provide actionable insights.
• Partners with other Medicaid business units and functional areas.
• Provides training support and guidance for cost-effective claims review, processing, and service.
• Develops in-house expertise in medical claims coding and support staff’s pursuit of trainings and certifications.
• Works closely with the Program Integrity Officer, Claims Cost Management, and Claims Processing Organization to develop and implement processes for cost avoidance, minimization of claims overpayments and need for recoupments, coordination of resources, coordination of benefits, and payment recoupment.