Grievances & Appeals Representative

Humana • London, ND

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 an 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 are 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, andworks 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 Additional Job Description Training: Virtual training will begin on Monday, January 19th and run your first 5 weeks, Monday-Friday, 8am-4:30pm EST. Shift: Monday–Friday, 8am-5pm EST, but be flexible with your hours based on business needs to work possible overtime and weekends. No time off is allowed during training or your first 120 days. Grievances and Appeals (G&A) has an impact to our business and because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18 months. Additional Information Work at Home Guidance To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: o At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. o Satellite, cellular and microwave connection can be used only if approved by leadership. o Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. o Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

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
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Nice To Haves

• Associate's or Bachelor's Degree
• Prior experience with Medicare
• 1+ years of grievances and appeals experience
• Previous inbound call center or related customer service experience
• Previous experience processing medical claims
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• Experience with the Claims Administration System (CAS)
• Experience working with MHK (MedHOK)
• Knowledge of medical terminology
• Less than 2 years of leadership experience
• 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 an 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.
• Prioritizes requests and interpreting and adapting procedures, processes and techniques

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