Claims Processing Representative 2

Profile

Description

The Claims Processing Representative 2 reviews and adjudicates complex or specialty claims, submitted either via paper or electronically. The Claims Processing Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.

Responsibilities

Claims Processing Representative 2’s (claims processors) are part of a claims processing team in support of the TRICARE EAST contract. Claim processors typically work on routine and patterned assignments to make appropriate claim decisions based on strong knowledge of claims procedures, contract provisions, TRICARE Policy, and state and federal legislation. Claim processors also perform advanced operational and customer support duties that require independent initiative and judgment.


Analyze claims to determine if eligibility, pre-authorization and other claim filing requirements are met and make determinations. Identify when to pend to other departments based on guidelines. Translate, research, and verify claim information to determine if all requirements have been met.
Determine corrective action to be taken on various types of errors pended by the system and resolve interactive edits.
Contact providers and beneficiaries for missing claim information to process the claim through.
Interface and work with other Humana Government Business (HGB) departments, Wisconsin Physician Services (WPS), and Military Treatment Facility (MTF/TRO) customers to seek problem prevention and resolution.


Required Qualifications


U.S. Citizenship is required by our Department of Defense contract
Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
High School Diploma or GED
2 years of Claims Processing experience
Ability to understand claims adjudication, systems and reporting
Ability to manage and prioritize multiple initiatives with minimal guidance
Ability to promote teamwork and build effective relationships while meeting objectives
Excellent written and verbal communication skills and strong customer service skills
Ability to take initiative and meet objectives
High level of problem-solving and analytical skills
Ability to read and interpret documents such as contracts and operations manuals
Knowledge of HIPAA regulations
Proficient in Microsoft Office products, such as Word, Excel and Outlook
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


Medicare and/or TRICARE experience
Associate's Degree or Bachelor's Degree
Medical billing/coding experience
Knowledge in healthcare business applications and technology


Additional Information

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire Text to enhance our hiring and decision-making ability. Modern Hire Text allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected for a first round interview, you will receive a correspondence inviting you to participate in a Modern Hire Text interview. In this interview, you review a set of interview questions over your phone and you will provide text responses to each question. You should anticipate this interview to take about 15 to 20 minutes. Your text message interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

About Us

Mission: At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.

Equal Opportunity Employer

It is our policy to recruit, hire, train, and promote people without regard to race, color, religion, sex, national origin, age, sexual orientation, gender identity or expression, disability, or veteran status, except where age, sex, or physical status is a bona fide occupational qualification. View the EEO is the Law poster.

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