Claims Administrator - LA Medicaid

Humana Ama, LA 2019-07-09

Description

Humana’s Louisiana Medicaid Claims Administrator will be responsible for the administration of a comprehensive claims processing system capable of paying claims in accordance with state and federal requirements for Humana’s Louisiana Medicaid plan. They will oversee every aspect of the claims process, including initial claim payment, claim rework, claim-related inquiries from enrollees and providers, and other functions related to claims, such as billing, enrollment, accounts receivable, and provider data management.

Responsibilities

Humana’s Louisiana Medicaid Claims Administrator will be responsible for the administration of a comprehensive claims processing system capable of paying claims in accordance with state and federal requirements for Humana’s Louisiana Medicaid plan. They will oversee every aspect of the claims process, including initial claim payment, claim rework, claim-related inquiries from enrollees and providers, and other functions related to claims, such as billing, enrollment, accounts receivable, and provider data management.

Essential Functions and Responsibilities

  • Monitor prior authorization functions and assure that decisions are made in a consistent manner based on clinical criteria and meet timeliness standards
  • Develop, implement, and monitor the provision of care coordination, disease management, and case management functions
  • Ensure adoption and consistent application of appropriate inpatient and outpatient medical necessity criteria
  • Monitor claims administration areas to identify and minimize the impact of irregularities in claims processing
  • Utilize root-cause analysis to identify claims issues; manage the development and implementation of process improvement projects
  • Ensure that appropriate concurrent review and discharge planning of inpatient stays is conducted
  • Monitor, analyze, and implement appropriate interventions based on utilization data, including identifying and correcting over and underutilization of services
  • Provide training support and guidance for cost-effective claims review, processing, and service; develop in-house expertise in medical claims coding and support staff’s pursuit of trainings and certifications
  • Work closely with the Program Integrity Officer, Claims Cost Management and Claims Processing Organization to develop and implement processes for cost avoidance, minimization of claims overpayments and need for recoupments, coordination of resources, coordination of benefits, and payment recoupment

Required Education, Certification, & Experience Qualifications

  • Minimum five (5) years of claims management experience in the healthcare industry
  • Bachelor Degree in related field
  • Familiarity with medical terminology and ICD-9/ICD-10, CPT, HCPCS
  • Thorough understanding of claims adjudication processes required
  • Proven analytical skills
  • Excellent communication skills, both oral and written
  • Comprehensive knowledge of Microsoft Office tools such as Word, Excel and PowerPoint
  • Proficient with Visio and Process Map Development

Preferred Experience Qualifications

  • Lean or Six Sigma certified
  • PMP certified
  • Louisiana-licensed Registered Nurse

Scheduled Weekly Hours

40
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