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Claims Review Specialist
2 months ago
We are seeking a highly skilled Claims Review Representative to join our team at Humana. As a Claims Review Representative, you will play a critical role in analyzing overpaid claims and making determinations based on strong knowledge of claims procedures, contract provisions, and CMS guidelines.
Key Responsibilities- Claims Analysis: Conduct thorough analysis of overpaid claims to identify root causes and make appropriate determinations.
- Contract Review: Review contract provisions and CMS guidelines to ensure compliance and accuracy.
- Communication: Collaborate with other departments, including Claims, Finance, and Provider Services, to resolve claim issues and ensure timely resolution.
- Root Cause Analysis: Perform root cause analysis to identify opportunities to mitigate claim overpayments and improve processes.
- Experience: 2+ years of medical claims knowledge and/or claims processing experience within the healthcare industry.
- Skills: Proficiency in Microsoft Office applications, including Word, Excel, and Outlook.
- Time Zone: Must be able to work in Eastern Standard Time Zone.
- Schedule: Monday to Friday, 8 am to 5 pm EST, with flexibility in start/end time and overtime as needed.
- Financial Recovery Experience: Experience in sending/receiving overpayments correspondence, posting refund checks, and offsetting claim payments.
- Auditing Experience: Experience working in an auditing environment or similar role that requires determination based on research.
- Analytical Skills: Proven ability to utilize analytical thinking in determining root cause.
- Contract Interpretation: Experience interpreting provider contract language.
- DRG & APC Calculations: Experience with DRG & APC calculations.
- Competitive Pay: $40,200 - $55,200 per year.
- Benefits: Medical, dental, and vision benefits, 401(k) retirement savings plan, time off, and other opportunities.
