Grievances and Appeals Representative

The Grievances & Appeals Representative 3 manages members and provider PART B denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted. You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties. You will perform advanced administrative and customer support tasks that require independent initiative and judgment.

• Assist members and provider offices by phone
• Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, duel eligible Medicare/Medicaid, diabetic supply and related claims
• Follow company and department production goals and quality assurance (QA) metrics
• You will make decisions focused on methods, tactics and processes for completing administrative tasks/projects.
• You will exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques
• Work in a remote/work at home setting under limited guidance due

• 1 or more years of customer service (i.e. call center or retail) experience
• Experience in the healthcare industry, pharmaceutical industry or medical field
• 1 or more years of grievance and appeals (G&A) experience
• Experience in a production and quality assurance driven environment
• Strong data entry skills including the Microsoft office suite (Word and Excel)
• Must be able to work any day Sunday – Saturday, 8-hour shifts between the hours of 7 a.m.
  
  - 7 p.m. EST, but be flexible with your hours based on business needs to work possible overtime
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

• Previous experience processing medical claims (Ideally Part B Medical Pharmacy claims)
• Experience with Medicare or dual eligible Medicare/Medicaid plans
• Knowledge of medical terminology
• Experience managing large volume of documents including tracking, copying, faxing and scanning
• Experience with PaHub (For processing medical appeals)
• Prior experience working in a remote/work at home environment
• Excellent interpersonal skills with the ability to sensitively and compassionately interact with geriatric population

• Sunday-Saturday
• 8-hour shifts between the hours of 7 a.m.
  
  - 7 p.m. Eastern Standard Time (EST)
• Full-Time 40 hours a week
• Must be flexible with your hours based on our needs to include potential Overtime

Remote

Work at Home Requirements:
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. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

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) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge,…