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Humana Healthy Horizons in Oklahoma is seeking a Claims Research & Resolution Lead to lead a team that focuses on supporting providers in the claims submission process and ensures providers are reimbursed timely and accurately. The Claims Research & Resolution Lead will serve as a subject matter expert for the market on claims submission and billing practices, oversees related provider communications or training material development, and collaborates with enterprise teams to make changes to improve and internal processes or systems that may be contributing to claims denials and rework. They will receive assignments in the form of objectives and determines approach, resources, schedules, and goals.

The Claims Research & Resolution Lead works with insurance companies, providers, members, and collection services in the settlement of claims and advises executives to develop functional strategies (often segment specific) on matters of significance. The Lead exercises independent judgment and decision making on complex issues regarding job duties and related tasks and uses independent judgment requiring analysis of variable factors and determining the best course of action.

The Claims Research & Resolution Lead Key Responsibilities:

• Acts as a thought-leader and collaborates with Corp Shared Services and other leaders to ensure prompt and accurate provider claims processing.

• Establishes team norms and expectations for Claims Research & Resolution Professionals, including documentation, escalation pathways, and other processes.

• Serves as a claim’s submission and billing subject matter expert, answering questions, and providing appropriate guidance to Claims Research & Resolution Professionals.

• Monitors findings from Claims Research & Resolution Professionals root cause analyses and share recommendations with senior market leadership and other enterprise teams, on opportunities for process improvement.

• Oversees development of provider bulletins/communications or other educational materials, such as billing companion guides, related to claims submission processes, coding updates, etc.

• Partners with the Provider Relation’s team and other internal teams to conduct targeted training for providers and their staff to address high rates of claim denials or patterns of denied claims identified via root cause analysis.

• Interfaces with the Provider Call Center to gather information from provider calls related to claims to inform tracking and trending of issues and identify opportunities to for provider education.

• Ensures compliance with Oklahoma’s Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes.

• Manages teamwork assignments to ensure adequate coverage to meet quality and service levels.

• Conducts regular performance evaluation of employees and provides ongoing feedback and coaching as necessary to achieve service, quality, and production goals.

Use your skills to make an impact

Required Qualifications

• Must work hours in the central standard time zone in the United States and be available to travel up to 20% in the State of Oklahoma.

• Bachelor's degree -OR- 5+ years of technical experience with claims resolution and problem solving.

• 2+ years of project leadership experience.

• 5+ years of health insurance claims experience, such as claims education, claims processing.

• Experience working for or with key provider types (primary care, FQHCs, hospitals, nursing facilities, and/ Long Term Services and Supports (LTSS) and Behavioral Health and Certified Community Behavioral Clinics (CCBHCs).

• Experience analyzing data to track and trend common claims issues and root cause analysis.

• Exceptional time management and ability to manage multiple priorities in a fast-paced environment.

• Experience working collaboratively across multiple functional areas and fostering teamwork.

• Excellent communication skills (written, oral, and presentation skills).

• Ability to use data and analytical thinking to make fact-based decisions and/or recommendations.

• Advanced proficiency in Microsoft Office applications, including Word, Excel, and PowerPoint.

• This role is a part of Humana’s Driver Safety program and therefore requires an individual to have a valid state driver’s license and proof of personal vehicle liability insurance with at least 100,000/300,000/100,000 limits.

Preferred Qualifications

• Experience with Oklahoma Medicaid.

• Thorough understanding of managed care contracts, including contract language and reimbursement.

• Experience with Humana claims systems, adjudication, submission processes, coding, and/or dispute resolution.

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.

• Satellite, cellular and microwave connection can be used only if approved by leadership.

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Additional Information

• Workstyle: Remote, work from home.

• Travel: Up to 20% travel in Oklahoma.

• Direct Reports: 5-7 associates.

• Core Workdays & Hours: Typically, Monday – Friday 8:00am – 5:00pm Central Standard Time (CST).

• Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more.....

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue, 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

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$94,900 - $130,500 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 04-29-2025

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.