Grievances and Appeals Representative

Humana

1d • $43,000 - $56,200 • Remote

About The Position

The Grievances & Appeals Representative 3 manages members and provider denials and concerns through conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted. You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties. You will perform advanced administrative and customer support tasks that require independent initiative and judgment.

Requirements

• 1 or more years of customer service (i.e. call center or retail) experience
• Experience in the healthcare industry, pharmaceutical industry or medical field
• 1 or more years of grievance and appeals (G&A) experience
• Experience in a production and quality assurance driven setting
• Strong data entry skills including the Microsoft office suite (Word and Excel)
• Must be able to work Sunday – Saturday, between the hours of 8 a.m. - 7 p.m. EST, but adaptable with your hours based on business needs to work possible overtime
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Nice To Haves

• Previous experience processing medical claims (Ideally Part B Medical Pharmacy claims)
• Experience with Medicare or dual eligible Medicare/Medicaid plans
• Knowledge of medical terminology
• Experince managing large volume of documents including tracking, copying, faxing and scanning
• Experience with PaHub (For processing medical appeals)
• Prior experience working in a remote/work at home environment
• Excellent interpersonal skills with the ability to sensitively and compassionately talk with geriatric population

Responsibilities

• Assist members and provider offices by phone
• Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, duel eligible Medicare/Medicaid, diabetic supply and related claims
• Follow company and department production goals and quality assurance (QA) metrics
• Make decisions focused on methods and processes for completing administrative tasks/projects.
• Exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques
• Work in a remote/work at home setting under limited guidance
• Use your skills to make an impact

Benefits

• medical
• dental
• 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: No Education Listed