Title Grievances & Appeals Representative

Become a part of our caring community and help us put health first

The Grievances & Appeals Representative 2 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 2 performs varied activities and moderately complex administrative/operational/customer support assignments.

Performs computations. Typically works on semi-routine assignments.

The Grievances & Appeals Representative 2 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 interpretation of area/department policy and methods for completing assignments. Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction.

Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion.

• Minimum one, (1) year of customer service experience, healthcare industry or medical field experience.
• Must have experience in a production driven environment
• Intermediate experience with Microsoft Word and Excel
• Strong data entry skills required
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

• Associate's or Bachelor's Degree
• Previous experience in medical claims processing
• Grievance and appeals experience
• Medical terminology experience
• Prior experience with Medicare
• 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

Remote work at home

United States

• 40-hour schedule which will include a willingness to work Saturday and Sunday.
• Overtime during peak season between January through March and also during periods of high capacity, which will be based on business need.
• Shift will be discussed during the interview.

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.

Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from  with instructions on how to add the information into your official application on Humana’s secure website.

As part of our hiring process for this opportunity, we will be using an interviewing technology called Hire Vue to enhance our hiring and decision-making ability. Hire Vue 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.

Travel:
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

40

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week)…