[Hiring] Grievances & Appeals Representative @Humana

Role 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 final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. You will perform advanced administrative/operational/customer support responsibilities that require independent initiative and judgment.

• Assist members by phone to further/support quality related goals.
• Investigate and resolve member and practitioner issues.
• Decisions 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.
• Work independently with limited supervision, drawing on substantial experience of administrative responsibilities and organizational practices.

Qualifications

• Must reside in Puerto Rico.
• Bilingual (English and Spanish); with the ability to read, write, and speak in both languages with no limitations or assistance.
• Two (2) years of customer service experience.
• Experience working in the healthcare industry or a medical field.
• Experience working in a production driven environment.
• Proficient in data entry and record management, maintaining accuracy while meeting productivity goals.
• Intermediate experience with Microsoft Word and Excel.

Requirements

• Associate or bachelor's degree.
• Previous inbound call center or related customer service experience.
• Grievance and appeals experience.
• Previous experience processing medical claims.
• Prior experience with Medicare.
• Experience with the Claims Administration System (CAS).
• Knowledge of medical terminology.
• 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

• Competitive benefits that support whole-person well-being.
• 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 and many other opportunities.

Company Description

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it.