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Humana Healthy Horizons in Indiana is seeking a Senior Claims Research & Resolution Professional who is dedicated to reviewing provider claims ensuring prompt and accurate provider claims processing according to State reimbursement guidelines by applying guidance, and making appropriate decisions which may include interpretation of provider information or data. The claims review professional works in collaboration with the chief information officer (CIO) to ensure timely and accurate submission of encounter data and works with special investigation unit (SIU) on matters that require SIU review or investigation.

The Senior Claims Research & Resolution Professional exercises independent judgment and decision making on complex issues regarding job duties and related tasks, uses independent judgment requiring analysis of variable factors to determine the best course of action, and ensures compliance with Indiana’s Managed Care contractual requirements for claims dispute resolution within specified timeframes.

The Senior Claims Research & Resolution Professional Key Responsibilities:

• Acts as a thought-leader and collaborates with Corp Shared Services and other leaders to ensure prompt and accurate provider claims processing.
• Serve as the market point of contact and liaison with Technology teams to ensure accurate and timely encounter submissions.
• Works with the Special Investigation Unit (SIU) Manager to assure that service billing and utilization issues are documented and reported appropriately.
• Partners with the Provider Education and Outreach team to identify targeted training for Home-and-Community Based (HCBS)/Long Term Service Support (LTSS) providers.
• Responsible for annual and quarterly State reporting of grievance and appeals.
• Workstyle: Hybrid Office, required to work at the Humana Healthy Horizons office in downtown Indianapolis, or within 10 miles from the mile square of downtown Indianapolis, at least three days per week to coordinate with the State office.

Use your skills to make an impact
 

Required Qualifications

• Must reside in the state of Indiana, be able to travel in the state of Indiana, and work in the Indianapolis office at least three days per week.
• 3+ years of medical claims review experience.
• Advanced knowledge of Medicaid and Medicare claims processes.
• Demonstrated leadership experience.
• Ability to collaborate with shared services and interact with all levels of leadership.
• Proven problem solving and critical thinking skills.
• Excellent written and verbal communication skills.
• Knowledge of how business processes relate to data.
• Ability to analyze large data files to ensure claims are paying accurately before being released.
• Intermediate to Advanced knowledge of Microsoft Word, Excel, and Access.
• This role is a part of Humana’s Driver Safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.
• This role is considered patient facing and is a part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

Work at Home Requirements

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Humana will provide Home or Hybrid Home/Office associates 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.

Preferred Qualifications

• Bachelor’s degree.
• Experience working with HCBS, LTSS, Physical Health (PH), and Behavioral Health (BH) providers.
• Advanced proficiency working with healthcare data, specifically medical claims.
• Advanced proficiency with Excel (ability to create pivot tables and put it into consumable information).
• Experience using the following system: MHK, Availity, or APEX.

Additional Information:

• Workstyle: Hybrid Office, required to work at the Humana Healthy Horizons office in downtown Indianapolis, or within 10 miles from the mile square of downtown Indianapolis, at least three days per week to coordinate with the State office.
• Travel: Up to 15% travel in the state of Indiana to provider offices and Humana locations.
• Core Workdays & Hours: Typically, Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST).