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Humana Healthy Horizons in Oklahoma is seeking a Claims Research & Resolution Lead to lead a team that focuses on supporting providers in the claims submission process and ensures providers are reimbursed timely and accurately. The Claims Research & Resolution Lead will serve as a subject matter expert for the market on claims submission and billing practices, oversees related provider communications or training material development, and collaborates with enterprise teams to make changes to improve and internal processes or systems that may be contributing to claims denials and rework. They will receive assignments in the form of objectives and determines approach, resources, schedules, and goals.

The Claims Research & Resolution Lead works with insurance companies, providers, members, and collection services in the settlement of claims and advises executives to develop functional strategies (often segment specific) on matters of significance. The Lead exercises independent judgment and decision making on complex issues regarding job duties and related tasks and uses independent judgment requiring analysis of variable factors and determining the best course of action.

The Claims Research & Resolution Lead Key Responsibilities:

• Acts as a thought-leader and collaborates with Corp Shared Services and other leaders to ensure prompt and accurate provider claims processing.
• Establishes team norms and expectations for Claims Research & Resolution Professionals, including documentation, escalation pathways, and other processes.
• Serves as a claim’s submission and billing subject matter expert, answering questions, and providing appropriate guidance to Claims Research & Resolution Professionals.
• Monitors findings from Claims Research & Resolution Professionals root cause analyses and share recommendations with senior market leadership and other enterprise teams, on opportunities for process improvement.
• Oversees development of provider bulletins/communications or other educational materials, such as billing companion guides, related to claims submission processes, coding updates, etc.
• Partners with the Provider Relation’s team and other internal teams to conduct targeted training for providers and their staff to address high rates of claim denials or patterns of denied claims identified via root cause analysis.  
• Interfaces with the Provider Call Center to gather information from provider calls related to claims to inform tracking and trending of issues and identify opportunities to for provider education.
• Ensures compliance with Oklahoma’s Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes.
• Manages teamwork assignments to ensure adequate coverage to meet quality and service levels.
• Conducts regular performance evaluation of employees and provides ongoing feedback and coaching as necessary to achieve service, quality, and production goals.

Use your skills to make an impact
 

Required Qualifications

• Must work hours in the central standard time zone in the United States and be available to travel up to 20% in the State of Oklahoma.
• Bachelor's degree -OR- 5+ years of technical experience with claims resolution and problem solving.
• 2+ years of project leadership experience.
• 5+ years of health insurance claims experience, such as claims education, claims processing.
• Experience working for or with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/ Long Term Services and Supports (LTSS) and Behavioral Health and Certified Community Behavioral Clinics (CCBHCs).
• Experience analyzing data to track and trend common claims issues and root cause analysis.
• Exceptional time management and ability to manage multiple priorities in a fast-paced environment.
• Experience working collaboratively across multiple functional areas and fostering teamwork.
• Excellent communication skills (written, oral, and presentation skills).
• Ability to use data and analytical thinking to make fact-based decisions and/or recommendations.
• Advanced proficiency in Microsoft Office applications, including Word, Excel, and PowerPoint.
• 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.

Preferred Qualifications

• Experience with Oklahoma Medicaid.
• Thorough understanding of managed care contracts, i