[Remote] Job Posting Title Grievances & Appeals Representative

Note: The job is a remote job and is open to candidates in USA. Humana is a company committed to putting health first for its teammates and customers. The Grievances & Appeals Representative 2 manages client denials and concerns, conducting analytic reviews of clinical documentation to determine if grievances or appeals are warranted, while also assisting members and resolving issues.

Responsibilities

• Manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an 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 varied activities and moderately complex administrative/operational/customer support assignments
• Performs computations
• Typically works on semi-routine assignments
• 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 interpretation of area/department policy and methods for completing assignments
• Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction
• Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion

Skills

• Minimum one, (1) year of customer service experience, healthcare industry or medical field experience
• Must have experience in a production driven environment
• Intermediate experience with Microsoft Word and Excel
• Strong data entry skills required
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Associate's or Bachelor's Degree
• Previous experience in medical claims processing
• Grievance and appeals experience
• Medical terminology experience
• Prior experience with Medicare
• 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
• Many other opportunities

Company Overview

Company H1B Sponsorship