Grievance and Appeals Representative 3 - KY WI Southern Indiana or Tampa FL

Profile

Description

The Grievances & Appeals Representative 3 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. 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 and providers to investigate and resolve 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.

Competitive compensation with a strong hourly rate and bonus eligibility.

Benefits effective first day - no waiting period! Robust benefits as a full-time Humana associate include health, dental, vision, tuition assistance, 401(k) with stellar match, generous paid time off and more!

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

Prior experience with Medicare

Previous experience processing medical claims and interpreting member benefits

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. Ability to manage large volume of documents including tracking, copying, faxing and scanning.

Must be passionate about contributing to an organization focused on continuously improving consumer experiences. 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. Works well under minimal supervision and takes initiative.

Required Work Schedule :

Virtual Training will start day one of employment and runs for 5 weeks with a schedule of 8:00 am - 4:30 pm EST, Monday - Friday. Attendance is vital for success, so no time off - with the exception of Christmas Day 2022 and New Year's Day 2023 - is allowed during training.

Following training, must be available to work any shift between the hours of 8:00 am - 7:00 pm EST, Sunday - Thursday. Hours are subject to change based on business needs.

Mandatory Overtime may include weekend days and holidays, based on business needs.

No time off during the first 120 day appraisal period.

Must commit to working within the department for minimum of eighteen (18) months.

* LOCATION *

May need to occasionally come into the local Louisville, KY; Green Bay, WI; or Tampa, FL office. For that reason, candidates must reside no more than a 50 mile driving distance of our Louisville, KY; Green Bay, WI; or Tampa, FL offices (includes Southern Indiana).

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

Work at Home Requirements

Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 25x10 (25mbs download x 10mbs upload) is required.

Must have a dedicated space conducive to learning and keeping protected health information (PHI / HIPAA) of our members confidential. Your designated work location must be located away from other household distractions, including but not limited to ensuring that alternate caregiving arrangements are made for dependents or other members in the household.

Covid-19 Vaccine Policy

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field. Every associate and contractor who work inside a Humana facility or in the field, regardless of vaccination status, must complete a daily health screening questionnaire.

Additional Information

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.

#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 https://www.humana.com/legal/accessibility-resources?source=Humana_Website.

Company info

Humana Inc.
Website : http://www.humana.com