Claims Review Representative

Become a part of our caring community and help us put health first
The Claims Review Representative 3 makes appropriate claim decisions based on strong knowledge of claims procedures, contract provisions, and state and federal legislation. The Claims Review Representative 3 performs advanced administrative / operational / customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.
The Claims Review Representative 3 partners with professional staff on pre-screening reviews by applying guidance and making appropriate decisions which may include interpretation of provider information or data. Decisions are typically focused on methods, tactics, and processes for completing administrative tasks / projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques. Works under limited guidance due to previous experience / breadth and depth of knowledge of administrative processes and organizational knowledge.
Use your skills to make an impact
Required Qualifications
Must
currently
live in Puerto Rico
Requires 1 – 3 years of technical experience; working knowledge of computers or a demonstrated technical aptitude
Previous claims or accounting inventory experience
Less than 2 years of leadership experience
Intermediate mathematical skills
Proficiency in Microsoft Office applications Word, Excel, and Outlook
Ability to quickly learn new systems
Ability to manage and prioritize tasks based on business need
Training
Virtual training starts on day one of employment and will run for the first 5+ weeks with a schedule of 7:00 AM to 4:00 PM Eastern, Monday - Friday.
You must be on time, dressed appropriately / camera ready, with your camera ON during training and for other meetings required by leadership.
Attendance is vital for your success; no time off will be allowed during training and is discouraged during your 120 Appraisal Period.
The initial 120 days of employment as a Claims Review Representative 3 constitute an appraisal period. This Appraisal Period is essential to your learning and development, which is why we ask for perfect attendance during both the training and nesting periods.
This position requires learning many systems, policies, and tools, and it takes time to become proficient in the role.
You must be willing to remain in this position for a period of twelve (12) months before applying to other Humana opportunities.
Work Hours Following 5 Week Training Period
Following training, associates are required to have flexibility to work an 8-hour shift between the hours of 6:00 AM and 4:30 PM Eastern time, Monday - Friday.
Some weekends and overtime may be required, based on business needs.
Preferred Qualifications
Associate or Bachelor's Degree
Experience in the healthcare industry
Knowledge with CPT and ICD-9 terminology / codes
CAS and / or CCP experience
CIS / CIS Pro experience
Financial recovery experience
Overpayment experience
PrePay or Post Pay experience
Experience with Mentor software
Work at Home Guidance
To 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 suggested.
Satellite, cellular and microwave connection can be used only if approved by leadership.
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.
Additional Information
**PLEASE MAKE SURE YOU ATTACH YOUR RESUME TO YOUR APPLICATION (PDF OR WORD FORMAT) **
Interview Process
As part of our hiring process for this opportunity, we will be using technology called HireVue / Modern Hire to enhance our hiring and decision-making ability. HireVue / Modern Hire 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.
Text Prescreen: Shortly after submitting your application, you may receive both a text message and email requesting you to complete 10 to 15 prescreen questions with either yes or no answers. The text message may arrive prior to the email. If you prefer to answer via computer or tablet, wait for the email.
Video Prescreen: If you are successful with the Text Prescreen, you will receive another communication to record a Video Prescreen. This is an online video activity using your phone, tablet, or computer; however, most candidates prefer using a computer or tablet.
Interviews: Some candidates will be invited to interview. If so, the recruiter will reach out to schedule.
Offers: Finalists from the interview will be contacted by a recruiter to discuss an offer for the job
Note: Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed.
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.
$32,600 - $44,800 per year
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.
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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
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