Claims Research & Resolution Lead

Employment Type: Full-time

Position Overview

Become a part of our caring community and help us put health first. As the Claims Research & Resolution Lead, you will manage the full spectrum of claims operations, including customer contact, claim investigation, and settlement for both incoming and outgoing claims. This leadership role is responsible for approving all claim settlements and addressing issues of varying complexity, from moderate to substantial. Your expertise will be essential in ensuring claims are handled efficiently, fairly, and in alignment with organizational standards.

Key Responsibilities

• Collaborate with internal iCare/Humana departments to ensure successful project completion.
• Engage with insurance companies, providers, members, state and federal regulators, and collection services to facilitate the settlement of claims.
• Advise executives and senior leadership by developing functional strategies, often specific to particular segments, on matters of significance.
• Analyze large, complex data sets to develop and present strategic recommendations.
• Oversee claims research and settlement processes, providing effective team leadership.
• Demonstrate an ability to balance business objectives with people management.
• Deliver effective presentations to all levels of organizational leadership.
• Use your skills to make an impact.

Requirements

• Education: Bachelor’s degree in Business Administration, Finance, Information Systems, or related field.
• Experience:
  • Eight (8) or more years of technical experience in healthcare, medical economics, financial analysis, or claims operations.
  • Two (2) or more years of project leadership or management experience.
  • Experience in managing claims research, settlement processes, and providing effective team leadership.
• Location: Residency in either the State of Wisconsin or Louisville, Kentucky, is required.
• Technical Skills: Advanced proficiency in SQL, Excel, and Power BI for data analysis and reporting.
• Skills:
  • Demonstrated ability to analyze large and complex data sets to develop strategic recommendations.
  • Strong business acumen with excellent presentation and communication skills, including the ability to interact effectively with senior leadership and regulatory agencies.
• Recognition: Recognized for extraordinary and consistent performance in previous roles.

Additional Information

• Workstyle: Home. Associates' home office environment is their primary work location, but they will use Humana office space on an as-needed basis for collaboration and other face-to-face needs.
• Travel: Up to 25% - will be expected to travel as needed for required meetings both in and out of state.
• Work Schedule: Monday – Friday, 8:00 AM - 5:00 PM CST.

Work From Home (WAH) Internet Statement

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required.
• Wireless, wired cable, or DSL connection is suggested.
• Satellite, cellular, and microwave connections can be used only if approved by leadership.
• Employees who live and work from Home in the states of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Application Instructions

• Interview Technology: As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
• SSN Alert: Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number.

Company Information

• Location Type: [Information not provided]
• Salary: [Information not provided]