**Become a part of our caring community and help us put health first** Humana Fully Integrated Dually Eligible (HMO D-SNP) in IL, is seeking a Claims Research & Resolution Professional 2 claims educator, who will be responsible for carrying out Humana’s proactive approach to minimize claims denials through claims education and training. The Claim Research and Resolution Professional 2 reports to the Claims Research and Resolution Associate Director and is responsible for tracking and trending IL FIDE D-SNP claims data and completing root cause analyses of claims denials, 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 payments. This position involves 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. Key Role Objectives Routinely track provider claims data for providers in the IL FIDE network to identify trends in denials and rework the 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 that can be relayed to the provider. + Utilize process identified to track & trend provider inquiries to proactively identify issues + Identify recurring issues, conduct root cause analyses, and identify areas of improvement through extracting data from various resources + 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 providers’ behaviors post-training to ensure claim denial root causes are resolved + Escalate any trended claims issues stemming from internal systems issues to Provider Claims Manager and support development of systems issue resolution + Assist with content creation for billing forums with selected provider associations to share billing guidance and answer provider questions + Partner with Provider Relations Representatives to ensure prompt resolution of provider or state inquiries, concerns, or problems associated with claims payment to adhere to Managed Care contract requirements and to optimize provider experience and satisfaction + Submit and monitor Business Case Justification (BCJ), Incorrect Payment Audit Requests (IPAR) and follow progress through completion + Assist with the development and distribution of provider communications and/or other educational materials, such as billing guides, coding updates, etc. + Work with internal corporate partners to ensure cross-department communication and resolution of provider’s issues which include recoupments, clinical or post pay audit, authorization issues, check void/issue process, and member resources **Use your skills to make an impact** **Required Qualifications** + 2+ years of health insurance claims experience, with claims systems, adjudication, submission processes, coding, and/or dispute resolution and/or other related functions in healthcare/health insurance + Experience with IL Medicaid and FIDE D-SNP + Experience working with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers) + Experience working with Medicaid Long Term Support Services, (LTSS), waiver claims + Partners with Provider Relations Representatives to ensure prompt resolution of provider inquiries, concerns, or problems associated with claims payment. + Exceptional time management and ability to manage multiple priorities in a fast-paced environment + Experience analyzing data to track and trend common and complex claims issues **Preferred Qualifications** + Bachelor's degree + Minimum 3 years working knowledge of claims systems and billing requirements, examples of systems such as Claims Administration, Fee Schedule Management, etc. + Identifies problems, provides solutions, and coordinates with business teams to resolve claims issues + Knowledge of current Medicaid reform and regulatory requirements + Process-focused with ability to leverage and enhance existing processes and assess changes to enhance process + Intermediate to advanced working knowledge using MS Word, Excel, Claims Explorer, and PowerPoint + Monitor compliance and provide targeted support with LTSS EVV (Electronic Visit Verification) technologies + Thorough understanding of managed care contracts, including provider contract language and reimbursement + Excellent written and verbal communication skills **Additional Information** ​ **WAH Internet Statement** 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: **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. + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; 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 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. 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. $59,300 - $80,900 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. ​ **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.