Grievances amp Appeals Representative - San Juan PR.

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Job Information
Humana
Grievances & Appeals Representative - San Juan, PR.
in
San Juan
Puerto Rico
Description
The Grievances & Appeals Representative manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.
Responsibilities
The Grievances & Appeals Representative 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, works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
Required Qualifications
1-3 years of customer service 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
Must be able to work Mondays - Fridays 8:00am - 5:00pm but be flexible with your hours based on business needs to work possible overtime
Be prepared to work on a Saturday at the minimum once every six weeks
Must be able to speak, read and write in Spanish without limitations or assistance. English Language Proficiency Level - Moderate
Preferred Qualifications
Associate's or Bachelor's Degree
Previous inbound call center or related customer service 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 the ability to interact with geriatric population sensitively and compassionately
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:
Mondays to Fridays 8am to 5pm, able to do Overtime and flexibility to work on weekends.
Training:
3 to 4 weeks at office
Work Location (Address): 383 Ave FD Roosevelt San Juan PR 00918-2131 (HYBRID)
% Travel: Up to 5%
HIRING STATUS: Full Time
*Humana Perks:   *
Full time associates enjoy:  
Medical, Dental, Vision and a variety of other supplemental insurances  
Paid time off (PTO) & Paid Holidays 
401(k) retirement savings plan with a competitive match  
Tuition reimbursement and/or scholarships for qualifying dependent children
And much more! 
Social Security Task:
Alert: Humana values personal identity protection. Please be aware that applicants being considered for an interview will be asked to provide a social security number, if it is not already on file. When required, an email will be sent from **** with instructions to add the information into the application at Humana's secure website.
Virtual Pre-Screen:
As part of our hiring process for this opportunity, we will be using exciting virtual pre-screen technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected for a virtual pre-screen, you will receive an email and text correspondence inviting you to participate in a Modern Hire interview. In this virtual pre-screen, you will receive a set of questions to answer. You should anticipate this virtual pre-screen to take about 10-15 minutes.
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 ****

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