[Hiring] Claims Research & Resolution Representative @Humana

Role Description

Join Humana's dynamic Puerto Rico team as a Claims Research & Resolution Representative and make a meaningful impact every day! You'll be at the heart of our claims operations—connecting with providers and members to resolve and settle claims that shape the health industry. You'll use your expertise to investigate cases, approve settlements, and navigate complex administrative challenges. If you thrive in a fast-paced environment and enjoy making decisions that matter, Humana invites you to bring your initiative and experience to our mission-driven team.

• Work with providers, members, and third-party collection services to facilitate timely and accurate resolution of complex medical claims.
• Use in-depth knowledge of claims processes to investigate discrepancies, verify documentation, and ensure compliance with internal policies and regulatory standards.
• Collaborate with specialized team of claims, call center, and provider associates to research pending claims issues.
• Apply advanced judgment and discretion in determining appropriate methods, strategies, and workflows for managing administrative tasks and projects.
• Demonstrate a high level of autonomy, applying experience to resolve claims inquiries.

Qualifications

• MUST currently reside in Puerto Rico
• 1+ years of claims OR customer service experience.
• Must be able to communicate effectively in English, including speaking, reading, and writing, to perform the essential functions of the role. Final selected candidates will be required to complete a language proficiency assessment.

Requirements

• Virtual training begins in December 2026 and will last for approximately 8 weeks. Training will be held Monday through Friday, 8:00 am – 5:00 pm, Eastern Time.
• Attendance is vital for success; no time off is allowed during training or the first 120 days.
• Following training and a post-training support period, you must be able to work Monday through Friday between 6:00 am and 5:30 pm Eastern.
• Hours are subject to change based on business needs.
• This position includes a 9-month probationary period.
• This position requires learning many systems, policies, and tools, and it takes time to become proficient in the role.
• You must be willing to remain in this position for a period of eighteen (18) months before applying to other Humana opportunities.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
• While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Benefits

• Humana provides medical, dental and vision benefits.
• 401(k) retirement savings plan.
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave).
• Short-term and long-term disability.
• Life insurance and many other opportunities.