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The Senior Claims Research and Resolution Professional reports to the Claims Research and Resolution Lead and is responsible for tracking and trending Michigan Medicaid claims data and completing root cause analyses of claims denials or rework, underpayments, and claims errors. This role supports the Provider Relations team with appropriate claims submission processes and requirements, coding updates, and common billing errors to reduce claims denials and support accurate and timely provider payment. This position works assignments that are varied and frequently require interpretation and independent determination of the appropriate courses of action. The individual in this role understands department, segment, and organizational strategy and operating objectives, including their applications to assignments. The Senior Claims Research and Resolution Professional follows general guidance and processes and must use independent judgement to execute effectively on assigned work.

Position Responsiilities

+ Routinely track provider claims data for providers in the Michigan Medicaid network to identify trends in denials and rework.

+ Analyze claims denial and rework root causes to support determination of appropriate intervention.

+ Ensure minimization of claims recoupments for duplicate claims and corrected claims.

+ Conduct training in collaboration with Provider Relations on claims denials, rejections or underpayments related to high rate of claim denials, common claims errors, and provider complaints.

+ Assist the Provider Relations team with claims submission expectations including code edit tools and updates, remittance review, overpayment, appeal/dispute functionality, virtual credit card payment program/process, and medical record management.

+ Identify recurring issues, conduct root cause analyses, and identify areas of improvement through extracting claims data from various sources.

+ Assist with the development and distribution of provider communications and/or other educational materials, such as billing guides, coding updates, etc.

+ Partner with Provider Relations team to ensure prompt resolution of provider inquiries, concerns, or problems associated with claims payment to optimize provider experience and satisfaction.

+ Contribute to provider training on appropriate claim submission processes and requirements claims denials, rework, and/or underpayments based on trended provider claims issues and common claims errors and monitor provider behaviors post-training to ensure claim denial root causes are resolved.

+ Monitor providers post-training to ensure claim denial root causes are resolved.

+ Assist with content creation for billing forums with selected provider associations to share billing guidance and answer provider questions.

+ Work with internal corporate partners to ensure cross-department communication and resolution of provider’s issues which include recoupments, takebacks, clinical or post pay audit, authorization issues, check void/issue process, Availity, and member resources.

+ Submit and monitor Submit Business Case Justification (BCJ), Incorrect Payment Audit Request (IPAR), as needed.

+ Escalate any trended claims issues stemming from internal systems issues to Provider Claims Manager and support development of systems issue resolution.

+ Convene billing forums with selected provider associations to share billing guidance and answer provider questions.

+ Work with internal resources and systems (e.g., claims adjudication system) to provide the Perfect Experience in all provider interactions with Humana’s Michigan Medicaid plan related to claims.

+ Ensure compliance with Michigan’s Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes.

Use your skills to make an impact

Required Qualifications

+ 5+ years of technical experience with claims systems, adjudication, submission processes, coding, claims dispute resolution, and/or other related functions in health insurance.

+ Experience working in the health insurance industry.

+ Exceptional relationship management skills.

+ Experience reviewing and analyzing large sets of claims data.

+ Knowledge of Medicaid regulatory requirements.

+ Excellent written and verbal communication skills.

+ Proficiency in analyzing, understanding, and communicating complex issues.

+ Thorough understanding of managed care contracts, including contract language and reimbursement.

+ Exceptional time management and ability to manage multiple priorities in a fast-paced environment.

+ Knowledge of Microsoft Office applications. (Word, Excel)

+ Position is field based in Michigan and requires frequent travels to provider and Humana locations. 25% Travel as needed to provider offices and Market office for meetings.

+ The applicant must be located in or willing to relocate to Michigan.

Preferred Qualifications

+ Bachelor's degree highly preferred.

+ Experience with Michigan Medicaid.

+ Experience working with Availity.

+ Experience working for or with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers).

+ Monitor compliance and provide targeted support with EVV (Electronic Visit Verification) technologies, if LTSS contracted in the market.

+ Experience with Humana claims systems, adjudication, submission processes, coding, and/or dispute resolution.

Additional Information

Work At Home Requirements

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 required.

+ Satellite, cellular and microwave connection can be used only if approved by leadership.

+ 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.

Interview Format

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.

Social Security Task

Alert: Humana values personal identity protection. Please be aware that applicants being considered for an interview will be asked to provide a social security number, if it is not already on file. When required, an email will be sent from [email protected] with instructions to add the information into the application at Humana’s secure website.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay 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.

$71,100 - $97,800 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

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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.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.