Senior Claims Research amp Resolution Professional

Profile

Description

The Senior Claims Research & Resolution Professional works with operational teams, vendors, providers, and members in the processing of claims. Strong analytical skills focusing on accuracy and attention to detail. Product knowledge and experience with escalated claims review processes, clinical terminology, and regulatory requirements will be needed. Exercises independent judgment and decision making on complex issues requiring analysis of variable factors and determining the best course of action. The Senior Claims Research & Resolution Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Claims Research & Resolution Professional works with operational teams, vendors, providers, and members in the processing of claims. Serves as a content model expert and mentor to teams regarding policies, procedures, and regulatory requirements. Strong analytical skills focusing on accuracy and attention to detail. Product knowledge and experience with escalated claims review processes, clinical terminology, and regulatory requirements will be needed. Advises executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks. Works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.


Assist providers and Humana market offices with code editing questions related to hospital, ancillary and physician claims
Use your claims coding knowledge to build a greater understanding of disclosure requirements for information about code editing logic and how claims are impacted
Collaborate across the company and bring out the best in others to get to the right answers
Research operational issues as reported by Clinical Operations, Markets, Provider Contracting, Provider Relations and member support areas as it relates to authorization processing and claims payment.
Identify opportunities to improve operational processes. These improvements may include file enhancements, program operational changes or transaction process improvement.
Research to seek answers to relevant clinical, operational, & financial questions, and identify areas for improvement.
Investigates facts and develops solutions to problems during the design and planning phases.


Required Qualifications


Bachelor's degree
5 or more years of technical experience
Coding certification (Industry-recognized coding certification from AAPC. Apprentice status will not be considered.)
Extensive knowledge of medical claims processing and are familiar with ICD, CPT, HCPCS, revenue and DRG assignment
Demonstrated ability to get things done in a rapidly changing environment
Demonstrated ability to influence decision making in different contexts
Excellent verbal and written communication skills and ability to adapt your communication style for the audience
Basic proficiency with MS Office (Excel, Word, and Access)
Possess self-drive and strong initiative
Must be passionate about contributing to an organization focused on continuously improving consumer experiences


Preferred Qualifications


Experience with escalated claim inquiries and dispute resolution
Experience in managed care or health care administration


Additional Information

Scheduled Weekly Hours

40

Company info

Sign Up Now - MiamiCrossing.com