Grievances and Appeals Representative 3 - KY WI or PR

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Job Information

Humana

Grievances and Appeals Representative 3 - KY, WI or PR

in

San Juan

Puerto Rico

Description

Do you enjoy helping those in need? Do you love researching, analyzing medical documents to determine if something was missed? Have you ever considered yourself a detective for medical claims / member benefits? Well, if you answered yes to any of the above, you may be a great fit for Humana's Grievance & Appeals Representative 3 role!

The Grievance & 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 Grievance & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

Responsibilities

What we need your help with:

Managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.

Performing advanced administrative and/or customer support duties that require independent initiative and judgment.

From time to time, applying intermediate mathematical skills and regularly exercising discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques.

Working under limited guidance from the comfort of home due to previous experience/breadth and depth of knowledge of administrative processes and organizational processes.

What you get from your great work! Benefits and Perks of This Opportunity:

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!

The ability to cut your daily commute to less than a minute!! Yes, 100% Work at Home capability.

Extensive 100% virtual training program for the first 8-10 weeks, setting you up for immediate and future success.

Professional development opportunities, including career advancement and mobility, virtual learning platforms, networking opportunities through our network resource groups, mentoring programs and more.

What you need for success!

Required Qualifications

2 years working with customers in a fast-paced, production-driven, deadline-oriented environment.

Experience in the healthcare industry or medical field; knowledge of medical terminology.

Prior experience interpreting and processing Member Benefits and Medical Claims.

Ability to work overtime, including weekends

and

holidays, based on business needs.

Previous inbound call center or related customer service experience

Medicare experience

Experience with CMS Guidelines and remaining compliant

Experience with the ability to prioritize and manage inventory and workflow. Ability to manage large volume of documents including tracking, copying, faxing and scanning.

Customer-focused, analytical, sound decision making skills. Works well under minimal supervision and takes initiative.

Strong data entry / technical skills with the ability to work across multiple software systems and comfortable working remotely from home.

Intermediate experience with Microsoft Word and Excel.

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. Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Required Work Schedule

Virtual Training will start day one of employment and runs for 8 - 10 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, New Year's Day 2023, and Martin Luther King Day 2023 - is allowed during training.

Following training, must be available to work any shift between the hours of 8:00 am - 6:00 pm EST, Monday - Friday. Hours are subject to change based on business needs.

Mandatory Overtime may include weekend days

and

holidays, based on business needs.

May need to occasionally come into the local Louisville, KY, Green Bay, WI, or San Juan, PR office.

Preferred Qualifications

Associate's or Bachelor's Degree

Experience with Humana's Claims Administration and operating systems: MHK (MedHok), CCP/GCP/CAS, CI, CGX

1 - 3 years of grievance and appeals experience

Bilingual in English and Spanish with the ability to read, write and speak English and Spanish.

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.

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.

#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