Claims Research and Resolution Professional 2

Illinois, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates require at least 2 years of health insurance claims experience, including claims systems, adjudication, submission processes, coding, and dispute resolution within the healthcare or health insurance industry. Experience with IL Medicaid and FIDE D-SNP, as well as working with key provider types such as primary care, FQHCs, hospitals, nursing facilities, and HCBS/LTSS providers, is also necessary.

Responsibilities

The Claims Research & Resolution Professional 2 will track and trend claims data for the IL FIDE network to identify denial and rework root causes, conducting root cause analyses to minimize claims recoupments. This role involves collaborating with Provider Relations to provide training on claims denials, rejections, and underpayments, and assisting with claims submission expectations, remittance review, and virtual credit card processes. The professional will also contribute to provider training on appropriate claim submission, monitor provider behaviors post-training, escalate internal system issues, and assist in creating content for billing forums and provider communications.

Skills

Claims processing

Root cause analysis

Data tracking

Trend analysis

Provider relations

Claims denials

Rework

Underpayments

Billing errors

Coding updates

Claims submission

Medical record management

Appeals

Dispute resolution

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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