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The Senior Claims Research and Resolution Professional reports to the Claims Research and Resolution Lead and is responsible for tracking and trending Michigan Medicaid claims data and completing root cause analyses of claims denials or rework, underpayments, and claims errors. This role supports the Provider Relations team with appropriate claims submission processes and requirements, coding updates, and common billing errors to reduce claims denials and support accurate and timely provider payment. This position works assignments that are varied and frequently require interpretation and independent determination of the appropriate courses of action. The individual in this role understands department, segment, and organizational strategy and operating objectives, including their applications to assignments. The Senior Claims Research and Resolution Professional follows general guidance and processes and must use independent judgement to execute effectively on assigned work.

Position Responsiilities

• Routinely track provider claims data for providers in the Michigan Medicaid network to identify trends in denials and rework.
• Analyze claims denial and rework root causes to support determination of appropriate intervention.
• Ensure minimization of claims recoupments for duplicate claims and corrected claims.
• Conduct training in collaboration with Provider Relations on claims denials, rejections or underpayments related to high rate of claim denials, common claims errors, and provider complaints.
• Assist the Provider Relations team with claims submission expectations including code edit tools and updates, remittance review, overpayment, appeal/dispute functionality, virtual credit card payment program/process, and medical record management.
• Identify recurring issues, conduct root cause analyses, and identify areas of improvement through extracting claims data from various sources.
• Assist with the development and distribution of provider communications and/or other educational materials, such as billing guides, coding updates, etc.
• Partner with Provider Relations team to ensure prompt resolution of provider inquiries, concerns, or problems associated with claims payment to optimize provider experience and satisfaction.
• Contribute to provider training on appropriate claim submission processes and requirements claims denials, rework, and/or underpayments based on trended provider claims issues and common claims errors and monitor provider behaviors post-training to ensure claim denial root causes are resolved.
• Monitor providers post-training to ensure claim denial root causes are resolved.
• Assist with content creation for billing forums with selected provider associations to share billing guidance and answer provider questions.
• Work with internal corporate partners to ensure cross-department communication and resolution of provider’s issues which include recoupments, takebacks, clinical or post pay audit, authorization issues, check void/issue process, Availity, and member resources.
• Submit and monitor Submit Business Case Justification (BCJ), Incorrect Payment Audit Request (IPAR), as needed.
• Escalate any trended claims issues stemming from internal systems issues to Provider Claims Manager and support development of systems issue resolution.
• Convene billing forums with selected provider associations to share billing guidance and answer provider questions.
• Work with internal resources and systems (e.g., claims adjudication system) to provide the Perfect Experience in all provider interactions with Humana’s Michigan Medicaid plan related to claims.
• Ensure compliance with Michigan’s Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes.

Use your skills to make an impact
 

Required Qualifications

• At least 5 years of technical experience with claims systems, adjudication, submission processes, coding, claims dispute resolution, and/or other related functions in health insurance.
• Experience working in the health insurance industry.
• Exceptional relationship management skills.
• Experience reviewing and analyzing large sets of claims data.
• Knowledge of Medicaid regulatory requirements.
• Excellent written and verbal communication skills.
• Proficiency in analyzing, understanding, and communicating complex issues.
• Thorough understanding of managed care contracts, including contract language and reimbursement.
• Exceptional time management and ability to manage multiple priorities in a fast-paced environment.
• Knowledge of Microsoft Office applications. (Word, Excel)
• Position is field b