Description
The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if 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. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.
Responsibilities
Do you enjoy helping those in need? Do you love researching, analyzing medical documents to determine if something was missed? Have you ever considered yourself a detective for medical claims / member benefits? Well, if you answered yes to any of the above you may be a great fit for Humana’s Grievances & Appeals Representative 3 role.
What we need your help with:
Managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
Perform advanced administrative and/or customer support duties that require independent initiative and judgment.
From time to time apply intermediate mathematical skills and regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques.
Work under limited guidance at the comfort of your home due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
We are only considering candidates who live within 50 miles of one of the following locations:
Louisville, KY
Tampa, FL
San Antonio, TX
Green Bay, WI
San Juan, PR
Required Schedule:
Training: Virtual training will begin on day one of employment and runs for 10 weeks with a schedule of 8:30 am – 4:30 pm EST, Monday – Friday.
Please note that training is a critical stage of associate development. Attendance is vital for your success, so no time off, other than observed holidays, is allowed during training.
New Hire Training requires you to be appropriately dressed, on time and on camera via the facilitated Zoom classroom instruction for attendance.
Work Schedule: Your shift will fall between start time of business hours of 6:00 am to 6:00 pm in the time zone you are located, Monday – Friday.
(Mandatory Overtime and business need for inventory, may include weekend days and holidays. Hours are subject to change based on business needs but are always communicated ahead of the need. )
This role requires an 18-month commitment.
Required Qualifications – What you need for success!
2+ years working with customers in a fast-paced, deadline-oriented environment
Prior experience interpreting Member Benefits and Medical Claims
Experience with the ability to prioritize and manage inventory and workflow
Customer focused, analytical and decision-making skills
Strong technical skills with the ability to work across multiple software systems and comfortable work remote out of your home
High level of emotional intelligence with a proven ability to influence office culture and engagement in a positive manner
Position and training are Remote but are expected to visit/attend the office 1 to 2x/year
Preferred Qualifications – What you need to STAND OUT among the crowd!
Associate or Bachelor’s degree
Humana’s operating systems: MHK (MedHok), CCP/GCP/CAS, CI, CGX
Additional Information
Work at Home Requirements
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
Satellite, cellular and microwave connection can be used only if approved by leadership
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Interview Process
Prescreen : Shortly after submitting your application, you will receive both a text message and email requesting you to complete 10 to 15 prescreen questions with either yes or no answers. The text message may arrive prior to the email. If you prefer to answer via computer or tablet, wait for the email.
Assessment: If the prescreen is passed, you will receive another communication to take the Grievances and Appeals Assessment. This is an online activity where you will see a Realistic Job Preview to learn more about the job and then be asked to answer questions where 30 minutes should be set aside to complete. You can complete the assessment on your phone, tablet or computer; however, most candidates prefer using a computer or tablet.
Interviews : Some candidates will be invited to interview. If so, the recruiter will reach out to schedule. A writing sample may or may not be required.
Offers : Finalists from the interview will be contacted by the recruiter to discuss an offer for the job
Note : Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed.
This is a remote position
#LI-REMOTE
Scheduled Weekly Hours
40
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
At Jabil we strive to make ANYTHING POSSIBLE and EVERYTHING BETTER. With over 260,000 diverse, talented and dedicated employees across...
Apply For This JobAre you someone who never rests on their laurels, always strives to go above and beyond, and is committed to...
Apply For This Jobbr{display:none;}.css-58vpdc ul > li{margin-left:0;}.css-58vpdc li{padding:0;}]]> Job Description: We’re looking for a full/part-time patient care coordinator to primarily perform two functions:...
Apply For This JobWho is Taco Bell? Taco Bell was born and raised in California and has been around since 1962. We went...
Apply For This JobDescription: Clinic Setting Assisting with triage of patients Assist with daily preparation of exam rooms and by securing supplies and...
Apply For This JobJob Description Models and delivers a distinctive and delightful customer experience. Registers sales on assigned cash register, provides customers...
Apply For This Job