Senior Claims Specialist
Integrated Specialty Coverages, LLCSalary not specified
Full Time
Senior (5 to 8 years)
Not SpecifiedCompensation
Junior (1 to 2 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries
Requirements
- High School Diploma or equivalent
- Minimum of two years’ proven experience in processing and adjudicating medical claims, with a track record of accurate and timely claim review completion
- Proven ability to maintain confidentiality and handle sensitive information in compliance with organizational policies and applicable regulations
- Solid understanding of medical coding terminology, including CPT, ICD-9, and ICD-10 codes
- Proficient in Microsoft Office applications, specifically Word, Excel, and Outlook, to effectively manage documentation and communications
- Exceptional attention to detail and accuracy in reviewing and processing claims
- Ability to quickly adapt to and learn new systems and technologies relevant to claims processing
- Strong organizational skills with the capacity to manage and prioritize multiple tasks based on business needs
- Bilingual fluency in English and Spanish (preferred)
- Associate or bachelor’s Degree (preferred)
- Previous experience with CAS or MTV claims systems (preferred)
- Foundational knowledge of finance principles related to claims processing (preferred)
Responsibilities
- Makes appropriate claim decisions based on strong knowledge of claims procedures, contract provisions, and state and federal legislation
- Performs advanced administrative/operational/customer support duties that require independent initiative and judgment
- Applies intermediate mathematical skills
- Partners with professional staff on pre-screening review by applying guidance and making appropriate decisions, which may include interpretation of provider information or data
- Focuses decisions on methods, tactics, and processes for completing administrative tasks/projects
- Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques
- Works under limited guidance due to previous experience, breadth, and depth of knowledge of administrative processes and organizational knowledge
Skills
Key technologies and capabilities for this role
Questions & Answers
Common questions about this position
Is this position remote?
Yes, this is a remote opportunity.
What are the required qualifications for this role?
Required qualifications include a High School Diploma or equivalent, minimum of two years’ proven experience in processing and adjudicating medical claims, ability to maintain confidentiality, solid understanding of medical coding terminology including CPT, ICD-9, and ICD-10 codes, proficiency in Microsoft Office applications, exceptional attention to detail, ability to adapt to new systems, and strong organizational skills.
What benefits does Humana offer?
Benefits start on day 1 of employment and include a competitive 401k match, generous Paid Time Off accrual, tuition reimbursement, and parent leave.
What is the salary for this position?
This information is not specified in the job description.
What makes a strong candidate for this role?
A strong candidate has at least two years of experience in medical claims processing, knowledge of CPT, ICD-9, and ICD-10 codes, proficiency in Microsoft Office, and bilingual fluency in English and Spanish; preferred candidates have an Associate or Bachelor’s degree, experience with CAS or MTV systems, and foundational finance knowledge.
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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