Note: The job is a remote job and is open to candidates in USA. Humana is a company committed to putting health first for its teammates and customers. The Grievances & Appeals Representative 2 manages client denials and concerns, conducting analytic reviews of clinical documentation to determine if grievances or appeals are warranted, while also assisting members and resolving issues.
Responsibilities
- 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
- Performs varied activities and moderately complex administrative/operational/customer support assignments
- Performs computations
- Typically works on semi-routine assignments
- Assists members, via phone or face to face, further/support quality related goals
- Investigates and resolves member and practitioner issues
- Decisions are typically focus on interpretation of area/department policy and methods for completing assignments
- Works within defined parameters to identify work expectations and quality standards, but has some latitude over prioritization/timing, and works under minimal direction
- Follows standard policies/practices that allow for some opportunity for interpretation/deviation and/or independent discretion
Skills
- Minimum one, (1) year of customer service experience, healthcare industry or medical field experience
- Must have experience in a production driven environment
- Intermediate experience with Microsoft Word and Excel
- Strong data entry skills required
- 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
- Grievance and appeals experience
- Medical terminology experience
- Prior experience with Medicare
- 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
Benefits
- Medical, dental and vision benefits
- 401(k) retirement savings plan
- Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
- Short-term and long-term disability
- Life insurance
- Many other opportunities
Company Overview
Company H1B Sponsorship
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