• Job Description

  Req#: R-318569

  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

• About the company

  Humana looks at every facet of your life and works with you to create a path to health that fits your unique needs

Notice