Grievances amp Appeals Representative 3

Profile

Description

The Grievances & Appeals Representative 3 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

Responsibilities

The Grievances & Appeals Representative 3 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.


Assists members, via phone or written correspondence, further/support quality related goals.
Investigates and resolves member and practitioner issues.
Decisions are typically focused 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.


What we need your help with:


Manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
Perform advanced administrative and/or customer support duties that require independent initiative and judgment.
From time to time, apply intermediate mathematical skills and regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques.
Work under limited guidance at the comfort of your home due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.


COME GROW WITH HUMANA! BENEFITS DAY ONE - STELLAR 401K MATCH - PAID TIME OFF

Required Qualifications


1 - 3 years of customer service experience
1- 3 years of Medicaid or Medicare experience
1- 3 years of Grievance & Appeals and/or medical claims processing experience
Must have experience in the healthcare industry or medical field
Strong data entry skills required
Intermediate experience with Microsoft Word and Excel
Strong written and verbal communication skills
Must have experience in a fast-paced, production driven environment
Case management - ability to prioritize and manage inventory and workflow - strong attention to detail, organizational and time management skills
Schedule for this position is 8:00am -- 5:00pm EST Monday- Friday based on business needs with holiday and Saturday rotations as needed.
Flexibility - ability to work overtime including weekends, based on business needs
Must be passionate about contributing to an organization focused on continuously improving consumer experiences Work-At-Home Requirements
Must ensure designated work area is free from distractions during work hours and virtual meetings
Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required
Must commit to working within the department for minimum of eighteen (18) month


Preferred Qualifications


Associates or Bachelor's Degree
Previous inbound call center or related customer service experience
Previous experience interpreting member benefits
Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
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 our members


Additional Information

Training: Humana offers virtual training for the first 4-6 weeks following start. Attendance is required for your success.

Scheduled Weekly Hours

40

Company info

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