Grievances & Appeals Representative

Become a part of our caring community The Grievances & Appeals Representative 3 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. You will perform advanced administrative/operational/customer support responsibilities that require independent initiative and judgment. Assist members by phone to further/support quality related goals. Investigate and resolve member and practitioner issues. Decisions 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. Work independently with limited supervision, drawing on substantial experience of administrative responsibilities and organizational practices. Use your skills to make an impact Required Qualifications Must reside in Puerto Rico. Bilingual (English and Spanish); with the ability to read, write, and speak in both languages with no limitations or assistance. Two (2) years of customer service experience. Experience working in the healthcare industry or a medical field. Experience working in a production driven environment. Proficient in data entry and record management, maintaining accuracy while meeting productivity goals. Intermediate experience with Microsoft Word and Excel.

Associate or bachelor's degree. Previous inbound call center or related customer service experience. Grievance and appeals experience. Previous experience processing medical claims. Prior experience with Medicare. Experience with the Claims Administration System (CAS). 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.

Workstyle: This is a remote position. Work Schedule: Monday through Friday, 8:00 a.m. to 5:00 p.m.; however, candidates must be flexible to adjust their schedule and work overtime as business needs require. Start Date & Training Schedule: September 21 - Training will be conducted remotely and will last approximately 8–10 weeks. Attendance throughout the entire training period is mandatory, and we will not approve any time off requests during training. You must be available to fully participate in and successfully complete the training program as scheduled. Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a