Description
The Grievances & Appeals Representative 3 manages members and provider PART B denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted.
You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties.
You will perform advanced administrative and customer support tasks that require independent initiative and judgment.
Responsibilities:
- Assist members and provider offices by phone
- Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, duel eligible Medicare/Medicaid, diabetic supply and related claims
- Follow company and department production goals and quality assurance (QA) metrics
- Make decisions focused on methods, tactics and processes for completing administrative tasks/projects
- Exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques
- Work in a remote/work at home setting under limited guidance due
Required Qualifications:
- 1 or more years of customer service experience
- Experience in the healthcare industry, pharmaceutical industry or medical field
- 1 or more years of grievance and appeals experience
- Experience in a production and quality assurance driven environment
- Strong data entry skills including the Microsoft office suite (Word and Excel)
- Must be able to work any day Sunday – Saturday, 8-hour shifts between the hours of 7 a.m. - 7 p.m. EST, but be flexible with your hours based on business needs to work possible overtime
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications:
- Previous experience processing medical claims (Ideally Part B Medical Pharmacy claims)
- Experience with Medicare or dual eligible Medicare/Medicaid plans
- Knowledge of medical terminology
- Experience managing large volume of documents including tracking, copying, faxing and scanning
- Experience with PaHub (For processing medical appeals)
- Prior experience working in a remote/work at home environment
- Excellent interpersonal skills with the ability to sensitively and compassionately interact with geriatric population
Schedule:
- Sunday-Saturday
- 8-hour shifts between the hours of 7 a.m. - 7 p.m. Eastern Standard Time (EST)
- Full-Time 40 hours a week
- Must be flexible with your hours based on our needs to include potential Overtime
Work Style:
- Remote
Pay Range:
- $43,000 - $56,200 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