Claims Process and Policy Professional

Humana

6d•$53,700 - $72,600•Remote

About The Position

The Claims Process and Policy Professional 1 handles inquiries about claims and policy issues from beneficiaries, providers, vendors, internal partners, and external participants. The role researches claims for accuracy and completeness in relation to TRICARE rules and regulations, works with team members to obtain information, and adapts to an integrated work environment to provide complete and accurate answers to customers. Assignments are often straightforward and of moderate complexity. The position focuses on identifying root causes through established intake processes, researching claims to determine the impact of reported issues, and identifying improvement opportunities. The professional develops subject matter expertise, supports peers and Claims SMEs on complex issues, and builds knowledge of TRICARE rules, reimbursement methodologies, and claims processing. The role also requires integrity, meeting commitments, and taking responsibility for one's actions. This is a remote position with occasional travel to Humana offices for training or meetings. Employees working from home must have internet service with at least 25 Mbps download and 10 Mbps upload speeds and a dedicated workspace that protects member PHI/HIPAA information. The role is scheduled for 40 hours per week. U.S. citizenship and approval for government security clearance are required. Humana cannot hire candidates currently living in Puerto Rico for this position.

Requirements

At least 3 years of experience with a TRICARE contract working in claims processing, provider research, or benefit administration.
At least 3 years of experience analyzing data for reports.
Experience providing clear and concise written responses to customer inquiries.
Excellent communication and presentation skills, including the ability to communicate and present technical details to senior and executive-level leadership.
U.S. citizenship, as required by the Department of Defense contract.
Successfully receive approval for government security clearance through National Background Investigation Services (NBIS).
Candidates currently living in Puerto Rico are ineligible because Humana is not authorized to perform work there under its government contract.

Nice To Haves

Bachelor's degree.
Experience processing TRICARE claims.
Experience with SQL.

Responsibilities

Ensure appropriate identification of root cause through the established intake process.
Perform claims research to determine the impact of reported issues.
Identify improvement opportunities based on analysis.
Increase knowledge to become a claims subject matter expert.
Meet established expectations and achieve results.
Assist peers with root cause identification and Claims SMEs with more complex issues.
Attend required training to develop skills related to more complex topics.
Attend training opportunities that increase knowledge in other areas and improve claims processing.
Continue learning how the TRICARE program and reimbursement methodologies affect daily work.
Model and inspire integrity, meet commitment dates, and take responsibility for one's actions.
Perform other duties and tasks requested by a supervisor, consistent with the position, department, and company objectives.