Grievances amp Appeals Representative

Profile

Description

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 a final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment.

Why Humana?

At Humana, we know your well-being is important to you, and it's important to us too. That's why we're committed to making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. Just to name a few:


Work-Life Balance
Generous PTO package
Health benefits effective day 1
Annual Incentive Plan
401K- Immediate company match
Well-being program
Paid Volunteer Time Off
Career Growth: Role expansion/progression opportunities within the department as well as the opportunity to apply for roles outside of the department after 18 months of employment


Responsibilities

The Grievances & Appeals Representative 3 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.

The Grievances & Appeals Representative 3:


Assists members and providers to investigate and resolve grievances and appeals.
Decisions are typically focused 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.
Must be passionate about contributing to an organization focused on continuously improving consumer experiences.


*Are you looking for a CAREER and not just a JOB?*

Your FUTURE is here with us - COME GROW WITH HUMANA!

Required Qualifications


1 - 3 years of inbound call center or related customer service experience in a fast-paced, production driven environment
Must have experience in the healthcare industry or medical field and have knowledge of medical terminology
Strong data entry skills required with the ability to work across multiple software systems
Intermediate experience with Microsoft Word and Excel
Case management: ability to prioritize and manage inventory and workflow. Strong attention to detail, organizational and time management skills
High level of emotional intelligence with a proven ability to influence culture and engagement in a positive manner
Excellent interpersonal skills with ability to sensitively and compassionately interact with our members
Customer-focused, analytical, sound decision making skills, and able to work well under minimal supervision and take initiative
Meet all WAH requirements
Compliance with training and work schedule as stated below
Virtual Training will start day one of employment and runs the first 4 weeks Attendance is vital for success, so NO TIME OFF is allowed during training
Must attend all training classes on Webcam


**Work and Training Schedule Requirements:

Required Training Schedule:


Virtual Training will start day one of employment and runs for 4 weeks with a schedule of 8:30 am - 4:00 pm EST, Monday - Friday. Attendance is vital for success, so no time off is allowed during training.
Must attend all training classes on Webcam


Required Work Schedule


Following training, must be available to work the hours required per time zone from Tuesday - Saturday
Hours are subject to change based on business needs
Mandatory rotation for work on holidays
Must commit to working within the department for minimum of eighteen (18) months


If you live in the Eastern Time Zone (EST):


Training Schedule : Mandatory 8-week training Monday - Friday 8:00 a.m. to 4:30 p.m. EST
Work Schedule (Post training) : Must work 8:00 a.m. - 4:30 p.m. EST Tuesday - Saturday with overtime based on business need


If you live in the Central Time Zone (CST):


Training Schedule : Mandatory 4-week training Monday - Friday from 7:00 a.m. to 3:30 p.m. CST
Work Schedule (Post training) : Must work 8:00 a.m. - 4:30 p.m. CST Tuesday - Saturday with overtime based on business need


If you live in the Mountain Time Zone (MT):


Training Schedule : Mandatory 4-week training Monday - Friday from 6:00 a.m. to 2:30 a.m. MST
Work Schedule (Post training) : Must work 7:00 a.m. - 3:30 p.m. MST Tuesday - Saturday with overtime based on business need


If you live in the Pacific Time Zone (PT):


Training Schedule : Mandatory 4-week training Monday - Friday from 5:00 a.m. to 1:30 a.m. PST
Work Schedule (Post training) : Must work 6:00 a.m. - 2:30 p.m. PST Tuesday - Saturday with overtime based on business need


Work at Home Requirements


WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information


Preferred Qualifications


Associate's or bachelor's degree
Less than 2 years of leadership experience
1 - 3 years of grievance and appeals experience
Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
Experience with Humana's Claims Administration and operating systems: MHK (MedHok), CCP/GCP/CAS, CI, CGX
Experience with CMS Guidelines and remaining compliant


Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected for a first-round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate in a Modern Hire interview. In this interview, you will listen to a set of interview questions over your phone, and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

After submitting your application, if you are selected to move forward you will receive an email to complete the Grievance and Appeals Assessment. This is an online activity where you will be asked to answer questions and learn more about Grievance and Appeals jobs at Humana. Most people complete the assessment in 10 to 15 minutes. You can complete the assessment on your phone, tablet or computer.

Final interviews will be conducted via Modern Hire Video Interview and be 45 minutes. This will be a meeting with the hiring manager which will include a brief writing sample at the end. Interviews will start on 11/28/22 and run until 12/8/2022. This position will have a start date of 1/3/2022.

#LI-REMOTE

Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ****

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