Grievances amp Appeals Representative 4 FULLY BILINGUAL English/Spanish Remote anywhere with-in Eastern Time Zone

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Job Information

Humana

Grievances & Appeals Representative 4 (FULLY BILINGUAL English/Spanish) Remote, anywhere with-in Eastern Time Zone

in

Jersey City

New Jersey

Description

The Grievances & Appeals Representative 4 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative 4 assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties that require independent initiative and judgment.

Responsibilities

The Grievances & Appeals Representative 4 assists members, via phone or face to face, further/support quality related goals.

Investigates and resolves member and practitioner issues.

Decisions are regarding the daily priorities for an administrative work group and/or external vendors including coordinating work activities and monitoring progress towards schedules/goals, and often oversees work of others and/or is the primary administrative owner of a main process, program, product or technology.

Works within broad guidelines with little oversight.

Required Qualifications

2 - 4 years of customer service experience

1 - 5 years of leadership experience

Must have experience in the healthcare industry or medical field

Strong data entry skills required

Intermediate experience with Microsoft Word and Excel

Must have experience in a production driven environment

Work-At-Home Requirements:

WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

COVID Requirements

: For this job, associates are required to be fully COVID vaccinated, including booster or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.

If progressed to offer, you will be required to:

Provide proof of full vaccination, including booster or commit to testing protocols

*OR  *

Provide proof of applicable exemption including any required supporting documentation

​​ Medical, religious, state and (remote-only) work exemptions are available.

Preferred Qualifications

Associate's or Bachelor's Degree

Previous inbound call center or related customer service experience

2 - 4 years of grievance and appeals experience

Previous experience processing medical claims

Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

Additional Requirements

Hours:

Monday to Friday from 8 am to 5 pm, Overtime availability and as per business needs.

Mandatory for the final candidate to take and pass a Language Proficiency Assessment.

Scheduled Weekly Hours

40

Company info

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