Grievances & Appeals Representative

Humana • Puerto Rico, TX

20h • $34,400 - $45,000 • Remote

About The Position

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. You will perform advanced administrative/operational/customer support responsibilities that require independent initiative and judgment.
Assist members by phone to further/support quality related goals.
Investigate and resolve 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.
Work independently with limited supervision, drawing on substantial experience of administrative responsibilities and organizational practices.

Requirements

• Must reside in Puerto Rico.
• Bilingual (English and Spanish); with the ability to read, write, and speak in both languages with no limitations or assistance.
• Two (2) years of customer service experience.
• Experience working in the healthcare industry or a medical field.
• Experience working in a production driven environment.
• Proficient in data entry and record management, maintaining accuracy while meeting productivity goals.
• Intermediate experience with Microsoft Word and Excel.
• Self-provided internet service must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Nice To Haves

• Associate 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

• Assist members by phone to further/support quality related goals.
• Investigate and resolve member and practitioner issues.
• Conduct a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted.
• Deliver final determination based on trained skillsets and/or partnerships with clinical and other Humana parties.
• Perform advanced administrative/operational/customer support responsibilities that require independent initiative and judgment.
• Make decisions that typically focus on methods, tactics and processes for completing administrative tasks/projects.
• Regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques.
• Work independently with limited supervision, drawing on substantial experience of administrative responsibilities and organizational practices.

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: Associate degree