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

Ready for a new challenge? 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 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

What you need for success! Required Qualifications

• 1 - 3 years of technical experience
• Must live in Puerto Rico
• Bilingual English/Spanish). Must be able to speak, read and write in both languages without limitations or assistance.
• 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
• Experience in working under processes that require production and metrics
• 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

What you need to STAND OUT in the crowd! 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

Language Proficiency Testing

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.

• Schedule: Monday to Friday with 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

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