[Hiring] Grievances and Appeals Representative @CenterWell

Role Description

Become a part of our caring community. The Grievances & Appeals Representative 3 (Part Time 24 hours a week) manages members and provider denials and concerns through conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted. You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties. You will perform advanced administrative and customer support tasks that require independent initiative and judgment.

• Assist members and provider offices by phone
• Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, dual eligible Medicare/Medicaid, diabetic supply and related claims
• Follow company and department production goals and quality assurance (QA) metrics
• Make decisions focused on methods and processes for completing administrative tasks/projects
• Exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques
• Work in a remote/work at home setting

Qualifications

• 1 or more years of customer service (i.e. call center or retail) experience
• Experience in the healthcare industry, pharmaceutical industry or medical field
• 1 or more years of grievance and appeals (G&A) experience
• Experience in a production and quality assurance driven setting
• Strong data entry skills including the Microsoft office suite (Word and Excel)
• Can work 8 hour shifts on Friday, Saturday and Sunday between the hours of 7 a.m. - 5 p.m. EST, but adaptable with your hours based on our needs
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Requirements

• Previous experience processing medical claims (Ideally Part B Medical Pharmacy claims)
• Experience with Medicare or dual eligible Medicare/Medicaid plans
• Knowledge of medical terminology
• Experience managing large volume of documents including tracking, copying, faxing and scanning
• Experience with PaHub (For processing medical appeals)
• Prior experience working in a remote/work at home environment
• Experience building relationships with the ability to sensitively and compassionately talk with geriatric population

Benefits

• Medical, dental and vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• Short-term and long-term disability
• Life insurance
• Many other opportunities

Additional Information

• Schedule: Friday, Saturday and Sunday, 8 hour shifts between the hours of 7 a.m. - 5 p.m. Eastern Standard Time (EST)
• Part Time 24 hours a week
• Must be flexible with your hours based on our needs
• Work Style: Remote
• Work at Home Requirements: Minimum download speed of 25 Mbps and upload speed of 10 Mbps required; wireless, wired cable or DSL connection suggested
• Travel: Occasional travel to Humana's offices for training or meetings may be required
• Scheduled Weekly Hours: 24
• Pay Range: $43,000 - $56,200 per year