Humana Inc. is hiring a Grievances & Appeals Representative to manage client denials and concerns. In this role, you will conduct comprehensive analytic reviews of clinical documentation to determine if a grievance or appeal is warranted, and drive resolutions focused on improving member experiences.
What You'll Do
- Manage client denials and concerns by conducting comprehensive analytic review of clinical documentation.
- 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, and customer support duties requiring independent initiative and judgment.
- Assist members, via phone or face to face, to further and support quality-related goals.
- Investigate and resolve member and practitioner issues.
- Prioritize requests and interpret and adapt procedures, processes, and techniques.
What We're Looking For
- 1 - 3 years of customer service experience.
- Less than 2 years of leadership experience.
- Experience in the healthcare industry or medical field.
- Strong data entry skills.
- Intermediate experience with Microsoft Word and Excel.
- Experience in a production driven environment.
- Ability to work Monday – Friday 8 - 5 with flexibility for possible overtime.
- Previous experience in the healthcare or medical fields.
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences.
Nice to Have
- Associate's or Bachelor's Degree.
- Previous inbound call center or related customer service experience.
- 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.
- Experience with the Claims Administration System (CAS) and MHK.
- 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.
Technical Stack
- Microsoft Word
- Microsoft Excel
- Claims Administration System (CAS)
- MHK
Benefits & Compensation
- Compensation: $43,000 - $56,200 per year
- 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
Work Mode
This is a remote position.
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.
