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.
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 English & Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English & Spanish.
Strong and proven experience with processing and adjudicating medical claims
CAS experience
Experience in working under processes that require production and metrics
Proficiency in Microsoft Office applications Word, Excel and Outlook
Experience in the healthcare industry
Knowledge with CPT and ICD-9 terminology / codes
Must be able to work overtime when required
Schedule: Monday to Friday from 6 am to 6 pm EST
Training: 4 weeks, 100% Virtual - starts on day one of employment and will run for the first 5+ weeks with a schedule of 7:00 AM to 4:00 PM Eastern, Monday - Friday. You must be on time, dressed appropriately / camera ready, with your camera ON during training and for other meetings required by leadership. Attendance is vital for your success; no time off will be allowed during training and is discouraged during your 120 Appraisal Period. The initial 120 days of employment as a Claims Review Representative 3 constitute an appraisal period. This Appraisal Period is essential to your learning and development, which is why we ask for perfect attendance during both the training and nesting periods.
This position requires learning many systems, policies, and tools, and it takes time to become proficient in the role. You must be willing to remain in this position for a period of twelve (12) months before applying to other Humana opportunities.
Must sit in Puerto Rico
Preferred Qualifications
CIS/CIS Pro experience
Knowledge with CPT and ICD9 terminology/codes
Proficiency in Microsoft Office applications including Word, Excel and Outlook
Please be advised, Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. Candidates must be tested in ALL languages listed on the description.
Additional Information - How we Value You
• Benefits starting day 1 of employment
• Competitive 401k match
• Generous Paid Time Off accrual
• Tuition Reimbursement
• Parent Leave
Work at Home Requirements
• To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
· 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
· Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
· 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
Interview Format
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Zoom to enhance our hiring and decision-making ability. HireVue screens 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.
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.$35,900 - $48,200 per year
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 Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
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 will never ask, nor require a candidate to provide money for work equipment and network access during the application process. If you become aware of any instances where you as a candidate are asked to provide information and do not believe it is a legitimate request from Humana or affiliate, please contact yourcareer@humana.com to validate the request
At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.
