Senior Medicaid Grievance and Appeals Professional - Oklahoma City OK

Profile

Description

The Senior Grievances & Appeals Professional will be dedicated to the State of Oklahoma business managing inquiries by conducting a comprehensive analytic review of contract requirements. The Senior Grievances & Appeals Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

Where you Come In

The Senior Grievances & Appeals Professional manages enrollee and provider disputes arising under Humana's Oklahoma Grievance System, including enrollee grievances, appeals, State Fair Hearings, provider complaints, and claims-related disputes (the Grievance System.) They will ensure timely, complete responses to members and providers. They will identify trends and emerging issues, and recommend solutions to Humana's oversight committees. The Senior Grievances & Appeals Professional will also serve as the primary point of contact for the Oklahoma Health Care Authority (OHCA) for all issues related to the Grievance and Appeals System.


Oversee enrollee grievances, appeals, and State Fair Hearings under the Oklahoma Medicaid Managed Care Contract
Oversee provider complaints, claims-related disputes and arbitration proceedings under the Oklahoma Medicaid Managed Care Contract
Respond to communications from OHCA related to the Grievance System
Attend meetings with OHCA related to the Grievance System
Identify trends, conduct risk assessments, and identify areas of improvement resulting from information obtained through the Grievance System;
Ensure the coordination of the components of the Grievance System and Humana's Oklahoma Medicaid operations
Maintain the Grievance System records in compliance with contractual requirements
Ensure all actions are taken within the service level agreement and contractual requirements
Review processes regularly to identify areas of improvement


What Humana Offers

We are fortunate to offer a remote opportunity for this job. Our Fortune 100 Company values associate engagement & your well-being. We also provide excellent professional development & continued education.

Required Qualifications - What it takes to Succeed


Bachelor's degree in Business, Healthcare, or related field
Minimum five (5) years of facilitating working relationships and liaison work
Prior Medicaid experience
Technical and/or professional knowledge of grievance and appeals processes
Technical and/or professional knowledge of member and provider disputes
Proficient in MS Office
Able to exercise considerable independent judgment and initiative in performing case file investigation
Data trending and analysis experience
Stellar communication skills
Ability to uncover efficiencies and implement process improvements
Must live within 25 miles of Oklahoma City


Preferred Qualifications


Related experience in the healthcare industry
Experience working with state agencies
Previous experience in leading cross-functional teams on large-scale projects


Additional Information - 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

Must have a separate room with a locked door that can be used as a home office to ensure you have absolute and continuous privacy while you work.
Must have accessibility to high speed DSL or cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana systems is 10M x 1M


Interview Format

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate in a Modern Hire interview. In this interview, you will listen to a set of interview questions over your phone or text and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period of time. These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the coronavirus situation evolves. The following changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and wellbeing during the hiring process.

#ThriveTogether #WorkAtHome

Scheduled Weekly Hours

40

Company info

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