Grievance & Appeals Representative

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 supports members and providers by addressing concerns, resolving issues, and assisting with grievance and appeal processes. This role applies established policies and procedures while exercising judgment to prioritize work, interpret guidelines, and deliver quality service.

• Assist members and providers with grievance and appeal inquiries.

• Investigate and resolve member and practitioner concerns.

• Document interactions and maintain accurate records.

• Explain processes, policies, and resolution outcomes.

• Research issues and gather information to support case resolution.

• Apply departmental policies and procedures to assigned work.

• Prioritize workload and manage tasks to meet service expectations.

• Collaborate with internal teams to resolve complex issues.

• Escalate concerns requiring additional review or action.

• Support quality, compliance, and member experience goals.

• Previous customer service experience

• Previous experience in the healthcare industry or medical field

• Must have experience in a production driven environment

• Intermediate experience with Microsoft Word and Excel

• Ability to work an 8-hour shift Monday – Friday between the hours of 8am-8pm with flexibility to work overtime based on business needs

• 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

• Previous inbound call center or related customer service experience

• 1 - 3 years of grievance and appeals experience

• Medical terminology experience

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

• 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 ability to sensitively and compassionately interact with geriatric population

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…