You will perform analysis by reviewing claims payments, policies, procedures and determine root cause for issues. You will need a strong knowledge of claims and how to apply policy to claims processing accuracy. You may assist with benchmarking, business process analysis, claims processing, testing updates and claims quality audits. You will report to a Manager of Business Intelligence.
Accountabilities -
Ensure the appropriate identification of root cause through established intake process.
Performs claim analysis and summarize results with detail at the individual level and determine impacts.
Identifies improvement opportunities based on analysis.
Acts as a claims subject matter expert.
Required Qualifications
Our Department of Defense Contract requires U.S. citizenship for this position
Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Service)
HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico.
3 years of experience in managed care environment
4 years of claims experience processing/adjudicating professional, inpatient, and outpatient claims
Experience with TRICARE contracts and/or the military health care delivery system, or Medicare reimbursement
2 years of customer service experience
Familiarity with reimbursement terminology (ie DME, DRG, HCPCS, CPT coding, Revenue codes, etc)
Work at Home Requirements
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
Satellite, cellular and microwave connection can be used only if approved by leadership
Associates who live and work from Home in the state 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 associates 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
Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.