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.

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 English & Spanish. Must be able to speak, read and write in both languages without limitations or assistance.

• 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: approximately 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

According to Humana’s COVID-19 policy, vaccination and masking is required regardless of vaccination status (with exception for eating and drinking) for associates working in a clinical setting where patients receive care (e.g., pharmacy retail locations, clinics, home care). The policy only requires the primary series alone (first and second vaccine). Boosters are encouraged, but not required. Associates have the option to request an accommodation for medical, religious or other personal needs.

Preferred Qualifications

• 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

Work-At-Home Requirements

• WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
• 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.

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