Humana Hiring for Claims Review Representative 3 – Remote PR only Job at San Juan, PR Full Time

The Claims Review Representative 3 makes appropriate claim decision 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.

Responsibilities

Where you Come In

Humana is looking to add new associate to the PrePay Audit team in San Juan, PR. This Claims Review Representative 3 opportunity is 100% work-at-home position for the San Juan, PR office. The associate will make appropriate claim decision based on strong knowledge of claims procedures, contract provisions, and state and federal legislation. This role is involved in the pre-screening review process by applying guidance, and making an appropriate decision which may include interpretation of provider information or data. Will perform advanced administrative/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

• Candidates will be responsible for the review of all claims identified to have a potential overpayment opportunity.
• Claims are identified through queries and concepts developed in other areas within the Claims Cost Management (CCM) organization and delivered to the team via the EFR Audit Tool
• Partners with professional staff on pre-screening review by applying guidance, and making an appropriate decision which may include interpretation of provider information or data.

What Humana Offers

We are fortunate to offer a remote opportunity for this job. Our Fortune 100 Company values associate engagement & your well-being. We also provide excellent professional development & continued education.

Required Qualifications – What it takes to Succeed

• Fully Bilingual in Spanish. Must be able to speak, read and write in the Spanish language without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in Spanish.

• Proficiency in Microsoft Office applications Word, Excel and Outlook

• Experience in working under processes that require production and metrics

• Prior experience with inventory management, financial administrative task or related experiences.

• Must be able to work overtime when required

• Schedule: Monday to Friday from 6 am to 6 pm EST

• Associates earn vacation on a biweekly basis (18 days per calendar year). Vacation time can be taken after six months of employment. NO Exceptions.

• Training: 4 weeks, 100% Virtual

• Working knowledge of computers or a demonstrated technical aptitude

• Ability to quickly learn new systems

• Ability to manage and prioritize tasks based on business need

• Ability to multitask within different screens or tools

• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

• For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.

• If progressed to offer, you will be required to:

• Provide proof of full vaccination OR

• Commit to weekly testing, following all CDC protocols, OR

• Provide documentation for a medical or religious exemption consideration.

• This policy will not supersede state or local laws. Requests for these exemptions should be submitted at least 2 weeks prior to your scheduled first day of work.

Preferred Qualifications

• High School Diploma, GED or job related certification

• Associate’s or Bachelor’s Degree

• Knowledge with CPT and ICD9 terminology/codes

• Strong and proven experience with processing and adjudicating medical claims

• PMHS and/or CRM experience

Additional Information – How we Value You

• Benefits starting day 1 of employment

• Competitive 401k match

• Generous Paid Time Off accrual

• Tuition Reimbursement

• Parent Leave

• Go365 perks for well-being

• Must have a separate room with a locked door that can be used as a home office to ensure you have absolute and continuous privacy while you work.
• Must have accessibility to high speed DSL or cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 10M x 1M

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.

Scheduled Weekly Hours

40