Grievances amp Appeals Representative 3 -- Remote

Profile

Description

The Grievances & Appeals Representative 3 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

Responsibilities

The Grievances & Appeals Representative 3 assists members, via phone or written correspondence, 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.

Required Qualifications


Minimum 1 year of customer service experience
Intermediate experience with Microsoft Word and Excel
Strong communication skills both written and verbal
Must have experience in a fast-paced, production driven environment
Department Hours: Monday - Friday 8 - 5 but be flexible, overtime as needed. Hours subject to change based on business needs
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Associates working in the state of Arizona must comply with the Tobacco Free Hiring Policy (see details below under Additional Information) and upon offer will be subjected to nicotine testing as part of a 10-panel drug test


Work-At-Home Requirements


Must ensure designated work area is free from distractions during work hours and virtual meetings
Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 25x10 (25mbps download x 10mbps upload) for optimal performance of is required


Preferred Qualifications


Associate's or Bachelor's Degree
Letter writing experience
Previous inbound call center
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, Medicaid, or government lines of business
Experience with MedHok
Knowledge of medical terminology
Excellent interpersonal skills with ability to sensitively and compassionately interact with members


Additional Information


Must commit to working within the department for minimum of eighteen (18) months
At Humana, we know your well-being is important to you, and it's important to us too. We are committed in making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. If you share a real passion for helping people, we likely have the right place for you at Humana. The following policy applies only to associates working in the state of Arizona: We are committed in providing a safe and healthy work environment and to promoting the health and well-being of its associates. Effective July 1, 2011, we have adopted a tobacco-free hiring policy that will promote a healthier workplace and will not hire users of tobacco and nicotine products. If you have any questions, please consult with your recruiter.


Scheduled Weekly Hours

40

Company info

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