Grievances & Appeals Representative 2

The Grievances & Appeals Representative 2 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.

Responsibilities:

• Assist members and providers with grievance and appeal inquiries.
• Investigate and resolve member and practitioner concerns.
• Document interactions and maintain accurate records.
• Explain processes, policies, and resolution outcomes.
• Research issues and gather information to support case resolution.
• Apply departmental policies and procedures to assigned work.
• Prioritize workload and manage tasks to meet service expectations.
• Collaborate with internal teams to resolve complex issues.
• Escalate concerns requiring additional review or action.
• Support quality, compliance, and member experience goals.

Requirements:

• Previous customer service experience
• Previous experience in the healthcare industry or medical field
• Experience in a production-driven environment
• Intermediate experience with Microsoft Word and Excel
• Ability to work an 8-hour shift Monday – Friday between the hours of 8am-8pm with flexibility to work overtime based on business needs

Preferred Qualifications:

• Associate's or Bachelor's Degree
• Previous experience in medical claims processing
• Previous inbound call center or related customer service experience
• 1-3 years of grievance and appeals experience
• Medical terminology experience
• Bilingual (English and Spanish)
• Prior experience with Medicare
• Experience with the Claims Administration System (CAS)
• Knowledge of medical terminology
• Ability to manage large volume of documents
• Excellent interpersonal skills

Additional Information:

• Work from home requirements: minimum download speed of 25 Mbps and upload speed of 10 Mbps, dedicated workspace
• Occasional travel to Humana's offices for training or meetings may be required

Scheduled Weekly Hours: 40 Pay Range: $40,000 - $52,300 per year

Benefits:

• Medical, dental, and vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• Short-term and long-term disability
• Life insurance