Provider Claims Education Manager Medicaid

Profile

Description

Humana Healthy Horizons in Indiana is seeking a Provider Claims Education Manager(Manager, Claims Research & Resolution) who will lead a team that focuses on supporting providers in the claims submission process and ensures providers are reimbursed timely and accurately.. The Provider Claims Education Manager (Manager, Claims Research & Resolution) oversees a team of Provider Claims Educators who conduct root cause analyses of submitted claims to track and trend common claims denials, rework, and/or other issues. They will routinely educate providers on the claims submission process, coding updates, 'how-to' bill commonly mis-billed services, among other functions. In addition to leading this team, Provider Claims Education Manager(Manager, Claims Research & Resolution) will serve as a subject matter expert for the market on claims submission and billing practices, oversees related provider communications or training material development, and collaborates with enterprise teams to make changes to improve and internal processes or systems that may be contributing to claims denials and rework. They will receive assignments in the form of objectives and determines approach, resources, schedules, and goals.

Responsibilities

Establishes team norms and expectations for Provider Claims Educators, including documentation, escalation pathways, and other processes.

Serves as a claims submission and billing subject matter expert, answering questions and providing appropriate guidance to Provider Claims Educators.

Monitors findings from Provider Claims Educators' root cause analyses and share recommendations with senior market leadership and other enterprise teams, on opportunities for process improvement.

Oversees development of provider bulletins/communications or other educational materials, such as billing companion guides, related to claims submission processes, coding updates, etc.

Partners with the Provider Education and Outreach team and other internal teams to conduct targeted training for providers and their staff to address high rates of claim denials or patterns of denied claims identified via root cause analysis.

Interfaces with the Provider Call Center to gather information from provider calls related to claims to inform tracking and trending of issues and identify opportunities to for provider education.

Ensures compliance with Indiana's Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes.

Manages teamwork assignments to ensure adequate coverage to meet quality and service levels.

Conducts regular performance evaluation of employees and provides ongoing feedback and coaching as necessary to achieve service, quality, and production goals.

Required Qualifications

Must reside in the state of Indiana

Must be able to travel in the state of Indiana.

Bachelor's degree.

Five (5) years of technical experience with claims systems, adjudication, submission processes, coding, dispute resolution, and/or other related function.

Two (2) years of progressive leadership experience.

Experience reviewing and analyzing large sets of claims data.

Experience working for or with key provider types: primary care, FQHCs, hospitals, nursing facilities, and/or HCBS and LTSS providers.

Proficiency in analyzing, understanding, and communicating complex issues.

Knowledge of Microsoft Office applications.

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.

This role is considered patient facing and is a part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

Work at Home Requirements

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.

Preferred Qualifications

Experience with Indiana Medicaid.

Experience working with Availity.

Experience working with LTSS providers to include home- and community-based service (HCBS) providers and/or institutional-based service providers.

Additional Information:

Workstyle: Remote, but may vary due to travel and occasional onsite work at the Humana Healthy Horizons office in Indiana.

Travel: Up to 15% travel in the state of Indiana to provider offices and Humana locations.

Core Workdays & Hours: Monday - Friday; 8:00am - 5:00pm Eastern Standard Time (EST).

Direct Reports: Up to 6 associates.

Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes; 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more.....

Interview 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 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.

Social Security Task

Alert: Humana values personal identity protection. Please be aware that applicants being considered for an interview will be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana's secure website.

Scheduled Weekly Hours

40

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.

Company info

Humana Inc.
Website : http://www.humana.com