Location
Atlanta, GA, United States
Posted on
Jul 30, 2021
Profile
Description
The Senior Claims Research & Resolution Professional manages claims operations that involve customer contact, investigation, and settlement of claims for and against the organization. Approves all claims issues/complaints within contractual requirement both for and against the organization. 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
Description
The Senior Claims Research & Resolution Professional manages claims operations that involve customer contact, investigation, and settlement of claims for and against the organization. Approves all claims issues/complaints within contractual requirement both for and against the organization. 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 State Regulatory Agencies, providers, members, and external associations in the resolution of claims and provider operational issues/complaints. This position will trend identified issues, lead provider operational improvement initiatives, and will manage complex issues through resolution independently. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.
Required Qualifications
Bachelor's degree or 5 years working with Provider and claims data/equivalent experience
Humana Claims systems knowledge and/or experience (CAS)
Intermediate Microsoft Word, Excel, and Access Database and/or SQL skills
Certified Coder/Billing Experience
Experience in root cause analysis and issue resolution through cross-functional collaboration
Strong communication, critical thinking, problem resolution and interpersonal skills
3 years of Managed Care Experience, Medicaid and Medicare primarily
Work At Home requirements: Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Preferred Qualifications
Experienced in communicating with providers to address operational issues
Florida Medicaid Managed Care Experience/knowledge
Knowledge of cross-functional teams across Humana
Additional information
Schedule: Monday to Friday from 8 am to 5 pm.
Training: Remotely
Work Location (Address): Work at Home Nationwide
% Travel: Minimal
Scheduled Weekly Hours
40
Company info
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