Grievances and Appeals Representative

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $43k - $56.2k / year

⏰ Full Time

🟢 Junior

🚫👨‍🎓 No degree required

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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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

• Manage member and provider Part B denials and concerns • Conduct comprehensive analytic reviews of clinical documentation • Determine whether a grievance, appeal or further request is warranted • Deliver final determinations using trained skills and partnerships with clinical and other Humana teams • Assist members and provider offices by phone • Investigate and resolve member and practitioner issues involving Medicare Part B Pharmacy, dual eligible Medicare/Medicaid, diabetic supply and related claims • Meet company and department production goals and quality assurance metrics • Make decisions regarding methods, tactics and processes for administrative tasks and projects • Prioritize requests and interpret and adapt procedures, processes and techniques • Perform advanced administrative and customer support tasks independently

🎯 Requirements

• 1 or more years of customer service (i.e. call center or retail) experience • Experience in the healthcare industry, pharmaceutical industry or medical field • 1 or more years of grievance and appeals (G&A) experience • Experience in a production and quality assurance driven environment • Strong data entry skills including the Microsoft Office suite (Word and Excel) • Ability to work any day Sunday–Saturday, 8-hour shifts between 7 a.m. and 7 p.m. EST • Flexibility to work possible overtime based on business needs • Passion for continuously improving consumer experiences • Previous experience processing medical claims, ideally Part B Medical Pharmacy claims (preferred) • Experience with Medicare or dual eligible Medicare/Medicaid plans (preferred) • Knowledge of medical terminology (preferred) • Experience managing large volumes of documents, including tracking, copying, faxing and scanning (preferred) • Experience with PaHub for processing medical appeals (preferred) • Prior experience working in a remote/work-at-home environment (preferred) • Excellent interpersonal skills and ability to interact sensitively and compassionately with the geriatric population (preferred) • Minimum 25 Mbps download and 10 Mbps upload internet connection for home work • Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

🏖️ Benefits

• Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Personal wellness and smart healthcare decision support • Occasional travel to Humana's offices for training or meetings may be required