Claims Research & Resolution Representative

Become a part of our caring community Humana/iCare is looking for a Claims Research and Resolution Representative to join our growing team. Reporting to the Manager, Claims Research & Resolution, you will resolve complex claims processing issues.

You will work on provider claims projects, review complicated and unique claims scenarios, and serve as an important resource in identifying solutions. You will resolve member billing concerns, collaborate across departments to address operational challenges, and provide valuable recommendations that help improve processes and outcomes.

Coordinate exchange of provider information with appropriate iCare vendors (claims, pharmacy, subrogation and cost-saving). Respond to provider questions and issues regarding claims payment, in the form of review reopening's, reconsiderations, and member bills.

Communicate with iCare/Cognizant personnel to establish and document claims processing, pricing and network procedures. Provide prompt and excellent service to internal and external customers. Research and examine problem claims to determine the cause of the claim's problem status.

Escalate trends and educational opportunities to the appropriate contacts. Provide input and make recommendations for solutions to departmental and interdepartmental problems. Understand the complexity of the enrollment, benefit and authorization process as it relates to claims.

Help document interdepartmental procedures. Participate in claims related audits initiated by the State, CMS or outside vendors. Review IAR's generated by enrollment and submit to Cognizant accordingly, verifying adjustments have been made and closing the loop with all parties involved.

Perform administrative support tasks not limited to mailings, scanning and forwarding of claims. Maintain proficiency in department queues. Use your skills to make an impact Required Qualifications 1 or more years of experience in an HMO or health insurance environment. 1 or more years of experience analyzing and resolving complex claims.

Work within the Central Standard Time (CST) between the hours of 8am-5pm. Proficiency with Microsoft Office applications, including Excel, Word, and Outlook. Preferred Qualifications 1 or more years' experience with multiple product lines (HMO, Medicaid, and Medicare). 1 or more years of experience as a Customer Service or Provider Service Representative.

Experience with QNXT Reside within the State of WI Additional Information Workstyle: Home. Home workstyle is defined as remote but will use Humana office space on an as needed basis for collaboration and other face-to-face needs. Typical Work Days/Hours: Monday - Friday, 8:30am - 5:00pm Central Standard Time (CST) WAH Internet Statement 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 required; wireless, wired cable or DSL connection is suggested.

Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

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.

HireVue As part of our hiring process for this opportunity, we will use an interviewing technology called HireVue to enhance our hiring. HireVue allows us to quickly connect and gain valuable information from you on your relevant experience at a time that is best for your schedule.

Work at Home Requirements
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 required; wireless, wired cable or DSL connection is suggested.

In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.

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. $40,000 - $52,300 per year 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com. 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.