Claims Review Representative 3 Bilingual CPT ICD9 PMHS San Juan PR

Profile

Description

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

What we need your help with:

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.

COME GROW WITH HUMANA! BENEFITS START ON DAY ONE - STELLAR 401K MATCH - PAID TIME OFF - TUTION ASSISTANCE PROGRAMS - STELLAR WELLNESS/REWARDS PROGRAM

What you need for success! - Required Qualifications

2 years of experience reviewing and processing medical claims

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

Prior experience utilizing CPT, PMHS and ICD9, ICD10 terminology

Prior experience providing attention to detail and accuracy on reviewing medical claims

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

Must be able to work overtime when required

Work at Home Requirements

Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 25x10 (25mbs download x 10mbs upload) is required.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

What you need to be considered a Superstar! : Preferred Qualifications

Associate's or Bachelor's Degree

Over 4 years of medical claims processing experience

Experience in the CAS or MTV claims systems

Finance knowledge

Experience in Financial Recovery Area (Pre and Post Pay area)

Additional Information

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

If progressed to offer, you will be required to provide proof of full vaccination or documentation for a medical or religious exemption consideration where allowed by law. Requests for these exemptions should be submitted at least 2 week prior to your scheduled first day of work.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com