Grievances & Appeals Representative

at  Humana

BECOME A PART OF OUR CARING COMMUNITY AND HELP US PUT HEALTH FIRST

The G&A rep 3 investigates and resolves grievances and appeals submitted by members and providers. Exercises discretion and judgement in prioritizing cases and interpreting procedures and processes. Works under limited guidance and has excellent critical thinking skills. The rep will manage client denials and concerns by conducting a comprehensive analytic review of 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. Needs to be highly organized, able to multitask, prioritize and be able to work under strict deadlines and production and quality standards.
The G&A rep 3 investigates and resolves grievances and appeals submitted by members and providers. Exercises discretion and judgement in prioritizing cases and interpreting procedures and processes. Works under limited guidance and has excellent critical thinking skills. The rep will manage client denials and concerns by conducting a comprehensive analytic review of 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. Needs to be highly organized, able to multitask, prioritize and able to work under strict deadlines and production and quality standards.

REQUIRED QUALIFICATIONS

• 1 year of customer service experience
• Intermediate experience with Microsoft Word and Excel
• Strong communication skills both written and verbal
• Critical thinking skills
• Must have experience in a fast-paced, production driven environment
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

PREFERRED QUALIFICATIONS

• Associate’s or Bachelor’s Degree
• Letter writing experience
• Previous inbound call center
• 1-3 years of grievance and appeals experience
• Previous experience processing medical claims
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• Prior experience with Medicare, Medicaid, or government lines of business
• Experience with MedHok
• Knowledge of medical terminology
• Excellent interpersonal skills with ability to sensitively and compassionately interact with members
• Experience using CAS, CRM, CGX, and/or PA Hub

WORK-AT-HOME REQUIREMENTS

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:

• 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.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

DESCRIPTION OF BENEFITS

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our 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.

ABOUT US

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Please refer the Job description for details