Humana PPI/PrePay Specialist (Bilingual. Processing on-line group medical claims exp a MUST) - San Juan in San Juan, Puerto Rico

Role: Provider Payment Integrity Specialist Assignment: PrePay Audit-HHP-PR Location:San Juan, Puerto Rico. Annex building Hato Rey Facilities

Healthcare isn’t just about health anymore. It’s about caring for family, friends, finances, and personal life goals. It’s about living life fully. At Humana, we want to help people everywhere, including our associates, lead their best lives. We support our associates to be happier, healthier, and more productive in their professional and personal lives. We encourage our people to build relationships that inspire, support, and challenge them. We promote lifelong well-being by giving our associates fresh perspective, new insights, and exciting opportunities to grow their careers. At Humana, we’re seeking innovative people who want to make positive changes in their lives, the lives of our members, and the healthcare industry as a whole.

Assignment Capsule Be a part of the Provider Network Operations world -- collaborate cross functionally to identify process opportunities to improve the provider experience.

Humana is seeking a PNO specialist in financial recovery you will: collect and process data while directly responding to questions, resolving concerns, and providing guidance on transactions, inquiries and complaints from both internal and external customers.

  • Review the adjudication of claims for accuracy
  • Identify and report inconsistencies relative to the adjudication of claims for contract compliance
  • Analyze errors to determine their root cause and develop solutions to meet business objects in a timely fashion
  • Prepare and communicate issues and resolutions to supervisors and operational units
  • Compile monthly reports to determine where process improvements are needed
  • Review and update claims to determine Underpayments or Overpayments in the necessary systems
  • Receive and Manage Correspondence
  • Use reference tools and Mentor
  • Work PHMS cash posting
  • Process reversals of kick outs report
  • Seek for audit clarification when appropriate
  • Make determination on claims audit

Role Essentials

  • High School Diploma

  • 2 years of experience in processing on-line group medical claims

  • Proficiency in all Microsoft Office Programs, e.g. Word, PowerPoint, Excel, Access, etc.

  • Ability to type 50-55 wpm

  • Capacity to maintain confidentiality

  • Bilingual English/Spanish. Candidate selected will not be communicating in English with members.

Role Desirables * Associate’s or Bachelor’s Degree

  • CAS Knowledge

  • CPT/ ICD-10 Knowledge

Reporting Relationships You will report to a PNO Frontline Leader. This area is under the leadership of the SVP & Chief Operating Officer.

Additional Information

  • Schedule: Monday to Friday 7 am – 4pm, overtime if necessary after regular work hours and/or weekends *

At Humana, we know your well-being is important to you, and it’s important to us too. That’s why we’re committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. If you share our passion for helping people, we likely have the right place for you at Humana.

Title: PPI/PrePay Specialist (Bilingual. Processing on-line group medical claims exp a MUST) - San Juan

Location: Puerto Rico-San Juan

Requisition ID: 190140

Humana Inc., headquartered in Louisville, Ky., is a leading health care company that offers a wide range of insurance products and health and wellness services that incorporate an integrated approach to lifelong well-being. By leveraging the strengths of its core businesses, Humana believes it can better explore opportunities for existing and emerging adjacencies in health care that can further enhance wellness opportunities for the millions of people across the nation with whom the company has relationships.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. We also provide free language interpreter services. See our full accessibility rights information and language options.