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Description
The Lead, Claims Research & Resolution (Provider Claims Educator) for Louisiana Medicaid is fully integrated with the complaint, claims processing, and provider relations systems and facilitates the exchange of information between these systems and providers.
This role serves as the market liaison working collaboratively with all Humana business areas associated with claims processing lifecycle for the LA Medicaid Market, providing market oversight of the claims lifecycle and encounter process. Collaborates with shared services and guides our market team through the claims process to ensure that the introduction of new programs, benefits, and state initiatives are executed within Humana’s system(s) configuration. Leads claims research and resolution efforts in support of our provider claim inquiries, ensuring timely and necessary action by Humana business areas to resolve issues.
Advises executives to develop strategies on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks and works under minimal supervision; uses independent judgment requiring analysis of variable factors and determining the best course of action.ResponsibilitiesThe Medicaid Claims Research & Resolution Lead (Provider Claims Educator) for Louisiana Medicaid is fully integrated with the complaint, claims processing, and provider relations systems and facilitates the exchange of information between these systems and providers.This role serves as the market liaison working collaboratively with all Humana business areas associated with claims processing lifecycle for the LA Medicaid Market, providing market oversight of the claims lifecycle and encounter process. Collaborates with shared services and guides our market team through the claims process to ensure that the introduction of new programs, benefits, and state initiatives are executed within Humana’s system(s) configuration. Leads claims research and resolution efforts in support of our provider claim inquiries, ensuring timely and necessary action by Humana business areas to resolve issues.Advises executives to develop strategies on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks and works under minimal supervision; uses independent judgment requiring analysis of variable factors and determining the best course of action.Key Accountabilities Include:Develop the process and technology to intake, root cause and resolve provider claim disputes, educate providers, draft documentation, and communication updates, summarize issues and drive organizational improvements in claim payment accuracy.Educating in network and out of network providers regarding appropriate claims coding, electronic claims transactions and electronic fund transfer, and available MCO resources, such as provider manuals, websites, fee schedules, etc.Interfacing with the provider call center to compile, analyze, and disseminate information from provider calls;Identifying trends and guiding the development and implementation of strategies to improve provider satisfaction; and Frequently communicating (i.e., telephonic and on-site (Townhalls, Provider Advisory Councils, JOC meetings) with providers to ensure the effective exchange of information and to gain feedback regarding the extent to which providers are informed about appropriate claims submission practices. Serve as the market point of contact and liaison in overseeing accurate and timely encounter submissions and assist with resolving encounter rejections and technology solutions that result from inaccurate claim processing.Provide direct supervision and daily oversight of Claims Research & Resolution staffs’ work activities, performance, and productivity.Acts as a thought-leader and collaborates with Corp Shared Services and other leaders on department-wide initiatives to drive process improvement and claims operational efficiencies.Establish and implement “best practices” standard operating procedures for the LA Market Claims Research & Resolution staff.Must be passionate about contributing to an organization focused on continuously improving consumer experiences.Required Qualifications8+ years of healthcare operations experience5+ years management and supervisory experience of at least 5-10 direct reports in the healthcare fieldBachelor’s degree Working knowledge of Humana’s Claims Adjudication system, eHub, Claims Explorer and edifecs Experience with analyzing, understanding, and communicating trends.2+ years of project leadership experienceKnowledge of Medicaid regulatory requirementsIntermediate knowledge of Microsoft Word and ExcelWorking knowledge of how organization capabilities interrelate across departments. Capable of making decisions related to identifying and resolving complex technical and operational problems.Must be available for 25% travelPreferred QualificationsLA Medicaid Managed Care experienceSelf-starter who takes initiative and ownership and can succeed with minimal supervision or direct managerial oversightDemonstrate success at root cause problem solving and predicting the possible outcomes of action.Work-At-Home RequirementsTo ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggestedSatellite, cellular and microwave connection can be used only if approved by leadershipAssociates 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 informationAdditional InformationInterview Format As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.If you are selected to move forward from your application prescreen, you will receive an email correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. (please be sure to check your spam or junk folders often to ensure communication isn’t missed) If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.#LI-KK1#LI-RemoteScheduled Weekly Hours40
