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