Grievances & Appeals Representative
Humana Inc. is committed to putting health first for their customers and teammates. The Grievances & Appeals Representative 3 manages client denials and concerns by reviewing clinical documentation and delivering final determinations, while also performing advanced administrative and customer support duties.
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
- 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, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge
Skills
- 1 - 3 years of customer service experience
- Less than 2 years of leadership 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 able to work Monday – Friday 8 - 5 but be flexible with your hours based on business needs to work possible overtime
- Previous experience in the healthcare or medical fields
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- 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
Benefits
- 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
Company Overview