Grievances & Appeals Representative

Humana • Puerto Rico, TX

2d • Remote

About The Position

Become a part of our caring community and help us put health first The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills. The Grievances & Appeals Representative 3 assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions typically focus on methods, tactics and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge. Use your skills to make an impact Shift: Monday – Friday, 8am-5pm, but be flexible with your hours based on business needs to work possible overtime. The start date is in May. No time off will be allowed during training.

Requirements

• 2 years of customer service experience
• Must have experience in the healthcare industry or medical field
• Strong data entry skills required
• Intermediate experience with Microsoft Word and Excel
• Must have experience in a production driven environment
• Bilingual (English and Spanish); with the ability to read, write, and speak in both languages with no limitations or assistance

Nice To Haves

• Associate's or Bachelor's Degree
• Previous inbound call center or related customer service experience
• Grievance and appeals experience
• Previous experience processing medical claims
• Prior experience with Medicare
• Experience with the Claims Administration System (CAS)
• Knowledge of medical terminology
• Ability to manage large volume of documents including tracking, copying, faxing and scanning
• Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population

Responsibilities

• Manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties.
• Performs advanced administrative/operational/customer support duties that require independent initiative and judgment.
• Assists members, via phone or face to face, further/support quality related goals.
• Investigates and resolves member and practitioner issues.

Benefits

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees