Manager, Claims Research & Resolution

San Antonio, Texas, United States

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Not SpecifiedCompensation

Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess a Bachelor's degree or have 5 or more years of management experience. A minimum of 3-5 years of claims experience and 3 or more years of inventory management experience are required. Proficiency in Microsoft Office applications and strong presentation, written, and oral communication skills are also necessary. Claims rework experience and CAS experience are preferred.

Responsibilities

The Manager, Claims Research & Resolution will oversee the end-to-end claims research and resolution process, ensuring accuracy, efficiency, and compliance. They will lead, coach, and develop a team of claims professionals, manage and resolve complex claims cases, and ensure fair settlements. The role involves setting objectives, managing resources, monitoring progress, and collaborating with cross-functional teams. Responsibilities also include analyzing claims data to identify trends and drive process improvements, maintaining knowledge of industry regulations, and managing staff levels and budget.

Skills

Claims Management

Claims Research

Claims Resolution

Leadership

Team Management

Process Improvement

Data Analysis

Regulatory Compliance

Budget Management

Stakeholder Collaboration

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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