The Grievances & Appeals Professional 2 (formerly an Analyst role) assists team to further/support quality and compliance related goals. Analyze member/ provider Grievance and Appeals issues.
Coordinating work activities.
Often analyze work of others and/or is the primary administrative owner of a main process, program, product or technology.
Works within broad guidelines with little oversight. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Analyze member/ provider Grievance and Appeals issues AND ASSIGNS ACCORDINGLY.
1-3 years of prior grievance and appeals experience
Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. See Additional Information on testing
Strong analytical skills required
Strong data entry skills required
Experience handling multiple projects and assignments as directed by Management
Attentiveness to detail
WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
COVID Requirements: For this job, associates are required to be fully COVID vaccinated, including booster or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to:
Provide proof of full vaccination, including booster or commit to testing protocols OR
Provide proof of applicable exemption including any required supporting documentation
Medical, religious, state and (remote-only) work exemptions are available.
Strong knowledge in Microsoft Access or experience with SQL Server databases
Schedule: Monday to Friday from 8 am to 5 pm, Overtime as needed per business need.
Language Proficiency Testing: Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government
Scheduled Weekly Hours