Senior Claims Research & Resolution Professional

Michigan, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess over 5 years of technical experience with claims systems, adjudication, submission processes, coding, and claims research and resolution. A strong understanding of Michigan Medicaid claims data, root cause analysis, and provider relations support is essential. The role requires independent judgment and the ability to interpret and determine appropriate courses of action.

Responsibilities

The Senior Claims Research and Resolution Professional will track and trend Michigan Medicaid claims data, analyze root causes of denials and rework, and ensure minimization of recoupments. They will collaborate with the Provider Relations team to provide training on claims submission processes, coding updates, and common billing errors. This role involves identifying recurring issues, assisting with provider communications and educational materials, and partnering with internal teams to resolve provider inquiries and payment issues. Additionally, they will submit and monitor business case justifications, escalate internal system issues, and ensure compliance with Michigan's Managed Care Contractual requirements for provider relations.

Skills

Claims Data Analysis

Root Cause Analysis

Medicaid Claims

Claims Denials

Claims Rework

Underpayments

Claims Errors

Provider Relations

Claims Submission Processes

Coding Updates

Billing Errors

Training

Remittance Review

Appeals

Dispute Resolution

Medical Record Management

Data Extraction

Independent Judgment

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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