Claims Research and Resolution Professional 2

About the Role

Humana is seeking a Claims Research & Resolution Professional 2 for their Fully Integrated Dually Eligible (HMO D-SNP) in IL plan. This role is responsible for carrying out Humana’s proactive approach to minimize claims denials through claims education and training.

Key Responsibilities

• Track and trend IL FIDE D-SNP claims data to identify root causes of claims denials, rework, underpayments, and claims errors.
• Conduct training in collaboration with Provider Relations on claims denials, rejections, or underpayments related to high rates 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.
• Utilize identified processes to track and trend provider inquiries to proactively identify issues.
• Identify recurring issues, conduct root cause analyses, and identify areas of improvement by extracting data from various resources.
• 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.
• Monitor providers’ behaviors post-training to ensure claim denial root causes are resolved.
• Escalate trended claims issues stemming from internal systems issues to the Provider Claims Manager and support the development of systems issue resolution.
• Assist with content creation for billing forums with selected provider associations to share billing guidance and answer provider questions.
• Partner with Provider Relations Representatives to ensure prompt resolution of provider or state inquiries, concerns, or problems associated with claims payment.
• Submit and monitor Business Case Justification (BCJ), Incorrect Payment Audit Requests (IPAR) and follow progress through completion.
• Assist with the development and distribution of provider communications and/or other educational materials, such as billing guides, coding updates, etc.
• Work with internal corporate partners to ensure cross-department communication and resolution of provider issues.

Required Qualifications

• 2+ years of health insurance claims experience, with claims systems, adjudication, submission processes, coding, and/or dispute resolution and/or other related functions in healthcare/health insurance.
• Experience with IL Medicaid and FIDE D-SNP.
• Experience working with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers).