Humana Looking For Puerto Rico – Claims Review Representative 3 – Remote/Virtual (CPT, ICD9, ICD10) 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

The Claims Review Representative 3 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. Decisions are typically focus on methods, tactics and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.

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 25×10 (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

Required Qualifications

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

1 – 3 years of technical experience

3 years of strong and proven experience with processing and adjudicating medical claims

Proficiency in Microsoft Office applications including Word, Excel and Outlook

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

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

Preferred Qualifications

Associate’s or Bachelor’s Degree

Knowledge with CPT, ICD9, and ICD10 terminology/codes

CAS and/or CCP experience

CIS/ CIS Pro experience

Finance Knowledge

Additional Information

• Schedule: Monday to Friday – Availability between 6am to 5:30pm
• 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: 5-6 weeks 8am-5pm M-F

Scheduled Weekly Hours

40