Become a part of our caring community and help us put health first
 

Humana Healthy Horizons in Virginia is seeking a Claims Research & Resolution Lead who will lead a team that supports providers with the claims submission process and ensures providers are paid timely and accurately as a result. This role oversees a team of Claims Educators who track, trend, and identify root causes of common claims submission and/or processing issues, and routinely educate providers on claims submission procedures. In addition to leading this team, Claims Research & Resolution Lead will serve as a subject matter expert (SME) for the Virginia market on claims submission and billing practices, support claims-related provider communications or training material development, and support claims-related operational improvement and optimization in collaboration with relevant enterprise teams, such as claims processing. This position works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules, and goals.

Position Responsibilities:

• Establish team norms and expectations for Provider Claims Educators, including research & resolution procedures, escalation pathways, and other processes

• Provide claims submission and billing subject matter guidance and direction to Provider Claims Educators

• Monitor Virginia market-level claims performance trends to identify opportunities for process improvement with senior market leadership and other enterprise claims operational teams

• Oversee development and distribution of provider communications and/or other educational materials, such as billing guides, coding updates, etc.

• Partner with Provider Relations and other internal teams to identify and address claims processing issues resulting from provider submission through targeted training with providers and their staff

• Monitor Provider Contact Center data to identify claims-related issues and opportunities for provider education

• Ensure compliance with claims-related Virginia contractual requirements, such as timeframes for claims processing, claims dispute resolution, etc.

• Manage team work assignments to ensure adequate coverage to meet quality and service levels

• Conduct regular performance evaluation of employees and provide ongoing feedback and coaching as necessary to achieve service, quality, and production goals

Use your skills to make an impact
 

Required Requirements

• Bachelor's degree

• 6+ years claims systems, adjudication, submission processes, coding, claims dispute resolution, and/or other related function

  2 years of progressive leadership experience

• Experience reviewing and analyzing large sets of claims data

• Experience working for or with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers)

• Exceptional relationship management skills

• Excellent written and verbal communication skills

• Proficiency in analyzing, understanding, and communicating complex issues

• Knowledge of Microsoft Office applications

• Must reside in Virginia with the ability to attend meetings in the Glen Allen facility

Preferred Requirements

• Experience with Virginia Medicaid
• Experience working with Availity
• Experience working with LTSS providers to include home- and community-based service (HCBS) providers and/or institutional-based service providers

Additional Information

This is a remote position in Virginia. May need to go into Humana office located in Glen Allen, VA.

Work at Home Criteria

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• 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 employees 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.

Interview Format

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us