Job Description

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.

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

Responsibilities

Do you want to work with members and providers to investigate and resolve grievance and appeal?

The 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 Humanas 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 or more years of Call Center or High Volume/Metric driven environment.
* 1 or more years experience working in a production goal/driven environment
* 1 or more years years experience in the Healthcare industry or Medical field (Production Goal oriented environment)
* Strong Data entry and Writing skills
* Working knowledge experience with Microsoft Word and Excel
* 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
* Must be able to work Monday Friday 8 - 5 and Saturday rotation 8-5. Flexible with your hours based on business needs to work possible overtime
* 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
* Prior job experience working with assigned cases with specific time-frames to resolve
* Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population
* 1-3 years of grievance and appeals experience

Additional Information

* Schedule: Monday Friday 8 am- 5 pm. Overtime based on business needs.
* 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.

For positions that are temporarily working at home due to COVID-19.

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 work-space for interview or work purposes. Humana continues to monitor the situation, and will adjust service levels as the COVID-19 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 well-being during the hiring process.

For in-office positions Restriction IF any recent international travel.

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. You may need a personal computing device with a camera and internet connection for interview purposes. This position will also be subject to restrictions for recent international travel. 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 well-being during the hiring process.

Internal Only- If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/Buzz and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.

Scheduled Weekly Hours

40