Grievance & Appeals Rep

Humana

1d • $43,000 - $56,200 • Remote

About The Position

The Grievances & Appeals Representative 3 manages client denials and concerns. This is done by conducting a comprehensive analytic review of clinical documentation to determine if an appeal, grievance, or further request is warranted. Then, the representative delivers a final determination based on trained skillsets or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support tasks that require independent initiative and judgment. The Grievances & Appeals Representative 3 assists members, by phone or face-to-face, further/support quality related goals. Investigate and resolve member and practitioner issues. Decisions are typically focus on methods and tactics for completing administrative tasks/projects. Exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.

Requirements

• 1 - 3 years of customer service experience
• Less than 2 years of leadership experience
• Experience in the healthcare industry or medical field
• Experience in a production driven environment
• Previous experience in the healthcare or medical fields
• Data entry skills
• Intermediate experience with Microsoft Word and Excel
• Will work Monday – Friday 8 - 5 but be flexible with your hours based on needs to work possible overtime

Nice To Haves

• Associate or bachelor's Degree
• Inbound call center or related customer service experience
• 1+ years of experience
• Experience processing medical claims
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• Experience with Medicare
• Experience with the Claims Administration System (CAS)
• Knowledge of medical terminology
• Manage large volume of documents including tracking, copying, faxing and scanning

Responsibilities

• Conducts a comprehensive analytic review of clinical documentation to determine if an appeal, grievance, or further request is warranted.
• Delivers a final determination based on trained skillsets or partnerships with clinical and other Humana parties.
• Performs advanced administrative/operational/customer support tasks that require independent initiative and judgment.
• Assists members, by phone or face-to-face, further/support quality related goals.
• Investigates and resolves member and practitioner issues.
• Exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree