Humana Healthy Horizons in Louisiana is seeking a Manager, Claims Research & Resolution (Claims Administrator) who will be responsible for the administration of a comprehensive claims processing system capable of paying claims in accordance with state and federal requirements for Humana's Louisiana Medicaid plan. They will oversee every aspect of the claims process, including initial claim payment, claim rework, claim-related inquiries from enrollees and providers, and other functions related to claims, such as billing, enrollment, accounts receivable, and provider data management.
Responsible for the day to day operations of claims management and issue resolution staff.
Monitors prior authorization functions and assures that decisions are made in a consistent manner based on clinical criteria and meet timeliness standards.
Develops, implements, and monitors the provision of care coordination, disease management, and case management functions.
Ensures adoption and consistent application of appropriate inpatient and outpatient medical necessity criteria.
Monitors claims administration areas to identify and minimize the impact of irregularities in claims processing.
Identifies claims payment issues and responding to escalation.
Utilizes root-cause analysis to identify claims issues; manage the development and implementation of process improvement projects.
Ensures that appropriate concurrent review and discharge planning of inpatient stays is conducted.
Monitors, analyzes, and implements appropriate interventions based on utilization data, including identifying and correcting over and underutilization of services.
Provides training support and guidance for cost-effective claims review, processing, and service; develops in-house expertise in medical claims coding and support staff's pursuit of trainings and certifications.
Works closely with the Program Integrity Officer, Claims Cost Management and Claims Processing Organization to develop and implement processes for cost avoidance, minimization of claims overpayments and need for recoupments, coordination of resources, coordination of benefits, and payment recoupment.
Must reside in the state of Louisiana.
Minimum (2) years of claims management experience in the healthcare industry.
Three (3) years of leadership experience.
Experience in claims operation preferably in Medicaid.
Familiarity with medical terminology and ICD-9/ICD-10, CPT, HCPCS
Comprehensive knowledge of Microsoft Office tools such as Word, Excel and PowerPoint.
Proficiency in Visio and Process Map Development.
Thorough understanding of claims adjudication processes.
Proven analytical skills .
Proven ability to develop working relationships within a highly matrixed business environment.
Excellent communication skills, both oral and written
This role is a part of Humana's Driver Safety program and therefore requires an individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.
Must have the ability to provide a high speed DSL or cable modem for a home office.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.
Lean, Six Sigma and/or PMP certification.
Experience working with internal claims systems.
Workstyle : Hybrid Home - 3 -4 days/week remotely and 1 - 2 days/week in Humana's Metairie, LA location.
Travel: up to 10% as requested by business to Louisiana Department of Health (LDH) location.
Direct Reports: Up to 10 Associates.
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 correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. 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 or computer 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.
Scheduled Weekly Hours
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.