Grievance & Appeals Rep

Become a part of our caring community The Grievances & Appeals Representative 3 manages client denials and concerns. We do this by conducting a comprehensive analytic review of clinical documentation to determine if an appeal, grievance, or further request is warranted. Then, the representative delivers a final determination based on trained skillsets or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support tasks that require independent initiative and judgment. The Grievances & Appeals Representative 3 assists members, by phone or face-to-face, further/support quality related goals. Investigate and resolve member and practitioner issues. Decisions are typically focus on methods and tactics for completing administrative tasks/projects. Exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge. Use your skills to make an impact Required Qualifications 1 - 3 years of customer service experience Less than 2 years of leadership experience Experience in the healthcare industry or medical field Experience in a production driven environment Previous experience in the healthcare or medical fields Data entry skills Intermediate experience with Microsoft Word and Excel Will work Monday – Friday 8 - 5 but be flexible with your hours based on needs to work possible overtime Preferred Qualifications Associate or bachelor's Degree Inbound call center or related customer service experience 1+ years of experience Experience processing medical claims Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish Experience with Medicare Experience with the Claims Administration System (CAS) Knowledge of medical terminology Manage large volume of documents including tracking, copying, faxing and scanning Additional Information Workstyle: Remote Nationwide Interview Format: As part of our hiring process for this opportunity, we will use an interviewing technology called HireVue to enhance our hiring. HireVue allows us to quickly connect and gain valuable information from you about your relevant experience at a time that is best for your schedule. 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 remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual