Humana Looking For Grievance and Appeals Representative at Kentucky Full Time

The Grievances & Appeals Representative 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 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

Responsibilities

The Grievances & Appeals Representative:

• Assists members and providers to investigate and resolve appeals.
• Decisions are typically focused on methods, tactics and processes for completing administrative tasks/projects.
• Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
• Competitive compensation with a strong hourly rate and bonus eligibility.
• Benefits effective first day – no waiting period! Robust benefits as a full-time Humana associate include health, dental, vision, tuition assistance, 401(k) with stellar match, generous paid time off and more!

Required Qualifications

• 1 – 3 years of inbound call center or related customer service experience in a fast-paced, production driven environment
• Must have experience in the healthcare industry or medical field and have knowledge of medical terminology
• Prior experience with Medicare
• Previous experience processing medical claims and interpreting member benefits
• Strong data entry skills required with the ability to work across multiple software systems
• Intermediate experience with Microsoft Word and Excel
• Case management: ability to prioritize and manage inventory and workflow. Strong attention to detail, organizational and time management skills. Ability to manage large volume of documents including tracking, copying, faxing and scanning.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences. High level of emotional intelligence with a proven ability to influence culture and engagement in a positive manner. Excellent interpersonal skills with ability to sensitively and compassionately interact with our members.
• Customer-focused, analytical, sound decision making skills. Works well under minimal supervision and takes initiative.

Required Work Schedule:

• Virtual Training will start day one of employment and runs for 5 weeks with a schedule of 8:00 am – 4:30 pm EST, Monday – Friday. Attendance is vital for success, so no time off – with the exception of Christmas Day 2022 and New Year’s Day 2023 – is allowed during training.
• Following training, must be available to work any shift between the hours of 8:00 am – 7:00 pm EST, Sunday – Thursday. Hours are subject to change based on business needs.
• Mandatory Overtime may include weekend days and holidays, based on business needs.
• No time off during the first 120 day appraisal period.
• Must commit to working within the department for minimum of eighteen (18) months.
• May need to occasionally come into the local Louisville, KY or Green Bay, WI office. For that reason, strong preference for candidates within driving distance to our Louisville, KY and Green Bay, WI offices.

Preferred Qualifications

• Associate’s or Bachelor’s Degree
• Less than 2 years of leadership experience
• 1 – 3 years of grievance and appeals experience
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• Experience with Humana’s Claims Administration and operating systems: MHK (MedHok), CCP/GCP/CAS, CI, CGX
• Experience with CMS Guidelines and remaining compliant

Work at Home Requirements

• Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 25×10 (25mbs download x 10mbs upload) is required.
• Must have a dedicated space conducive to learning and keeping protected health information (PHI / HIPAA) of our members confidential. Your designated work location must be located away from other household distractions, including but not limited to ensuring that alternate caregiving arrangements are made for dependents or other members in the household.

Job Type: Full-time

Pay: $20.00 – $23.32 per hour

Benefits:

• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance
• Work from home

Schedule:

Supplemental pay types:

Application Question(s):

• MANDATORY -Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 25×10 (25mbs download x 10mbs upload) is required.

Must have a dedicated space conducive to learning and keeping protected health information (PHI / HIPAA) of our members confidential. Your designated work location must be located away from other household distractions, including but not limited to ensuring that alternate caregiving arrangements are made for dependents or other members in the household.

Experience:

• inbound call center or related customer service: 1 year (Required)
• medical terminology: 2 years (Required)
• Medicare: 1 year (Required)
• processing medical claims: 1 year (Required)
• data entry: 1 year (Required)
• Microsoft Word: 2 years (Required)
• Microsoft Outlook: 2 years (Required)
• Microsoft Excel: 2 years (Required)
• Manage large volume of documents: 2 years (Required)

Work Location: Remote