Grievances & Appeals Representative

Become a part of our caring community and help us put health first
 The Grievances & Appeals Representative 2 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. The Grievances & Appeals Representative 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments.

Are you looking for a way to impact Humana’s STARS ratings? Well look no further. Humana’s Internal Revenue Team is looking for someone who is excited about handling large volumes of inventory to distribute to associates who encompass two teams.  

In this role, you will be reviewing all cases types to determine who can work them and then assigning the case to the next available associate to work.  

You will be responsible for communicating via email and MedHok to leadership and other associates on who has been delegated which cases to work.  

Work hours are Monday – Friday (8:00am–4:30pm EST with a Friday late shift until 6:30 pm). There is also a rotating weekend shift, which could include Saturday and Sunday hours.

Use your skills to make an impact
 

Required Qualifications

• Minimum 1 year of customer service experience
• Minimum 1 year of data entry experience required
• Must have experience in a production driven environment
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Associate's or Bachelor's Degree
• Previous experience with MedHok, PaHub, and/or Service Read Only
• Previous experience in medical claims processing
• Previous inbound call center or related customer service experience
• Previous grievance and appeals experience
• Medical terminology experience
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• Prior experience with Medicare
• Experience with the Claims Administration System (CAS)
• Ability to manage large volume of inventory

Work at Home Guidance 

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates 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. 

· Associates who live and work …