Grievance and Appeals Representative 3

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, via phone or face to face, further/support quality related goals.

Investigates and resolves member and practitioner issues.

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.

Required Qualifications

High School Diploma

1 - 3 years of customer service experience

Must have experience in the healthcare industry or medical field

Prior experience with Medicare

Previous experience processing medical claims

Strong data entry skills required

Intermediate experience with Microsoft Word and Excel

Must have experience in a fast-paced, production driven environment

Case management - ability to prioritize and manage inventory and work flow - strong attention to detail, organizational and time management skills

Department Hours: Must be able to work Thursday- Monday 8 -4:30pm EST based on business needs. Schedule will be centered around Eastern Standard Time hours. Holidays may be required.

Flexibility - ability to work overtime including weekends, based on business needs

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

Must ensure designated work area is free from distractions during work hours and virtual meetings

Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required

Preferred Qualifications

Associate's or Bachelor's Degree

Less than 2 years of leadership experience

Previous inbound call center or related customer service experience

Previous experience interpreting member benefits

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 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 our members

Scheduled Weekly Hours

40

Company info

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