Physician Reviewer
Blank StreetSalary not specified
Part Time
Expert & Leadership (9+ years)
Not SpecifiedCompensation
Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries
Requirements
- Bachelor’s degree in business, healthcare administration, or related field, or equivalent experience
- Minimum of 3 years’ experience in claims review, healthcare operations, or insurance industry, with at least 1 year in a supervisory or team lead role
- Solid understanding of claims processing, insurance guidelines, and provider data interpretation
- Familiarity with relevant federal and state regulations, including HIPAA and other applicable compliance standards
- Proficiency in analyzing complex information and applying established guidance to make sound decisions
- Strong interpersonal, communication, and organizational skills
- Ability to work collaboratively with professional staff and cross-functional teams
- Strong inventory management skills
- Demonstrated ability to supervise, motivate, and provide day-to-day oversight to support and technical associates
- Skilled in coordinating schedules, managing workloads, and ensuring consistency in team execution
- Proven track record of holding team members accountable to established policies and procedures
- Experience handling escalated or complex issues in claims review or related functions
- Experience with claims management systems, electronic health records, or similar platforms
- Proficiency in Microsoft Office Suite or comparable software
- Commitment to upholding company policies and compliance standards, including information protection and privacy procedures
- Ability to maintain confidentiality and ensure secure handling of sensitive information
- Strong problem-solving skills and attention to detail
- Excellent time management and prioritization abilities
Responsibilities
- Make appropriate claim decisions based on strong knowledge of claims procedures, contract provisions, and state and federal legislation
- Work within thorough, prescribed guidelines and procedures; use independent judgment requiring analysis of variable factors to solve basic problems
- Collaborate with management and top professionals/specialists in selection of methods, techniques, and analytical approach
- Partner with professional staff on pre-screening review by applying guidance, and making an appropriate decision which may include interpretation of provider information or data
- Handle decisions related to schedule, plans, and daily operations
- Perform escalated or more complex work of a similar nature
- Supervise a group of typically support and technical associates; coordinate and provide day-to-day oversight to associates
- Ensure consistency in execution across team
- Hold team members accountable for following established policies
Skills
Key technologies and capabilities for this role
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