Manager Grievances amp Appeals - BILINGUAL English/Spanish - Doral FL

Profile

Description

The Manager, Grievances & Appeals 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 Manager, Grievances & Appeals works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.

Responsibilities

The Manager, Grievances & Appeals oversees day to day operations of the GA Professional 2. Their work consists of correctly identifying and assigning grievances and appeals to associates. This work is extremely time sensitive and compliance driven. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

Required Qualifications


High School Diploma
Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. See Additional Information on testing
3 years of grievance and appeals experience
1 years of management or leadership experience
Strong data entry skills required
Advanced experience with Microsoft Word and Excel
Strong knowledge in Microsoft Access or experience with SQL Server databases
Experience handling multiple projects and assignments as directed by Management
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Work At Home requirements (Temporary due to COVID-19) : 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


Bachelor's Degree or higher


Additional information


Schedule: Monday to Friday from 8 am to 5 pm.

Training: 2 months, virtual

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, Doral, FL 33172

Travel: 5%

# of Direct Reports: 8

Language Proficiency Testing (English/Spanish): 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

Company info

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