Grievance & Appeals Representative

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $40k - $52.3k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

📋 Description

• Assist members and providers with grievance and appeal inquiries • Investigate and resolve member and practitioner concerns • Document interactions and maintain accurate records • Explain processes, policies, and resolution outcomes • Research issues and gather information to support case resolution • Apply departmental policies and procedures to assigned work • Prioritize workload and manage tasks to meet service expectations • Collaborate with internal teams to resolve complex issues • Escalate concerns requiring additional review or action • Support quality, compliance, and member experience goals • Conduct comprehensive analytic reviews of clinical documentation to determine whether a grievance, appeal, or further request is warranted • Deliver final determinations based on trained skillsets and partnerships with clinical and other Humana parties • Perform administrative, operational, customer support activities, and computations

🎯 Requirements

• Previous customer service experience • Previous experience in the healthcare industry or medical field • Experience in a production-driven environment • Intermediate experience with Microsoft Word and Excel • Ability to work an 8-hour shift Monday–Friday between 8 a.m. and 8 p.m. • Flexibility to work overtime based on business needs • Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information • Self-provided internet service with at least 25 Mbps download and 10 Mbps upload speeds • Passion for contributing to continuous improvement of consumer experiences • Associate's or Bachelor's Degree preferred • Previous experience in medical claims processing preferred • Previous inbound call center or related customer service experience preferred • 1–3 years of grievance and appeals experience preferred • Medical terminology experience preferred • Bilingual English and Spanish ability preferred • Prior Medicare experience preferred • Experience with the Claims Administration System (CAS) preferred • Knowledge of medical terminology preferred • Ability to manage large volumes of documents, including tracking, copying, faxing, and scanning preferred • Excellent interpersonal skills and ability to interact sensitively and compassionately with the geriatric population preferred

🏖️ Benefits

• Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company holidays • Personal holidays • Paid parental leave • Paid caregiver leave • Short-term disability • Long-term disability • Life insurance • Opportunities supporting whole-person well-being and smart healthcare decisions • Remote work arrangement