Grievances amp Appeals Representative 3 FULLY BILINGUAL English/Spanish WAH FL

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Job Information
Humana
Grievances & Appeals Representative 3 (FULLY BILINGUAL English/Spanish) WAH FL
in
Miami
Florida
Description
The Bilingual Grievances & Appeals Representative 3 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 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.
How we Value You
Benefits starting day 1 of employment
Competitive 401k match
Generous Paid Time Off accrual
Tuition Reimbursement
Parent Leave
Go365 perks for well-being
Responsibilities
Do you like work with members and providers to investigate and resolve grievance and appeal?
The Bilingual Grievances & Appeals Representative 3 assists member via phone or letters to 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, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
Respond to complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and internal processing timelines and guidelines:
Collect, analyze and interpret trend information to address and resolve non-routine business-related concerns
Build Humana's brand image with employers, members, brokers, consultants, physicians, hospitals, regulators and legislators by providing effective and efficient service
Required Qualifications
High School Diploma or equivalent
1 years of experience analyzing and solving customer problems, OR 1 years of work experience in a related environment (i.e. office, administrative, clerical, customer service, etc.) using phones and computers as the primary job tools
1 years' experience in the Healthcare industry or Medical field (Production Goal oriented environment)
Strong Data entry and Writing skills
Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population
Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance.
Work At Home (WAH) - Temporary Due to COVID-19 emergency. Please note this permanent position allows you to work at home indefinitely until further notice. See additional information in section below.
WAH requirements: Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Preferred Qualifications
Associate's or Bachelor's Degree
1 or more years of Call Center or High Volume/Metric driven environment.
Prior job experience working with assigned cases with specific time-frames to resolve
Grievance and Appeals or Utilization Review experience
Additional Information
Schedule
: Must be able to work Monday - Friday 8:00 am - 5:00 pm, Saturday rotation 8:00 am-5:00 pm. Flexible with your hours based on business needs to work possible overtime
Training
: 1 month (Remotely)
Work Location (Address)
: This permanent job is working from Home temporary due to Covid 19 emergency. This position will deploy to the following location at a future date: 11430 NW 20th Street, Suite 300 | Miami, FL 33172
Travel: 5%
Grievance & Appeal 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 (Take your time completing this assessment). Your answers will be reviewed and you will subsequently be informed if you will be moving forward to the interview stage.
Language Proficiency Testing:
Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.
Scheduled Weekly Hours
40

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