Grievances amp Appeals Representative 3 Fully Bilingual English/Spanish San Juan PR

Profile

Job Information

Humana

Grievances & Appeals Representative 3 (Fully Bilingual English/Spanish) San Juan, PR

in

San Juan

Puerto Rico

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 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.

Required Qualifications

High School Diploma or equivalent

Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. See Additional Information on testing

1-3 years of customer service experience

1-3 years prior experience working in a production goal/driven environment

Prior job experience working with assigned cases with specific time-frames to resolve

Must have experience in the healthcare industry or medical field

Strong data entry skills required

Intermediate experience with Microsoft Word and Excel

Must be able to work Monday - Friday 8 - 5 but be flexible with your hours based on business needs to work possible overtime. On Call on Saturdays and Holidays.

Must have critical thinking skills

WAH requirements (temporary due to Covid-19 emergency):

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 10x1 (10mbs download x 1mbs upload) is required. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

Associate's or Bachelor's Degree

Previous inbound call center or related customer service experience

1-3 years of grievance and appeals experience

Less than 2 years of leadership 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

Prior experience in health care industry (Health Plan Insurance, Hospital, Pharmacy, etc.)

Additional information

G&A Assessment:

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

Schedule:

Monday to Friday 8am to 5pm, able to do Overtime and flexibility to work on weekends. On Call on Saturdays and Holidays.

Training

: 3 to 4 weeks - Virtual

Language Proficiency Testing (English/Spanish):

Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

Work Location (Address

): This permanent job is working from Home temporary due to Covid 19 emergency. This position will deploy to the following location at a future date 383 Ave FD Roosevelt San Juan PR 00918-2131

% Travel

: 5%

Scheduled Weekly Hours

40

Company info

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