DescriptionThe Grievances & Appeals Representative 3 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.
The Grievances & Appeals Representative 3 assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions are typically focus 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.
- High School Diploma or equivalent
- 1-3 years of customer service experience
- Strong data entry skills required
- Intermediate experience with Microsoft Word and Excel
- Must have experience in a production driven environment
- Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish without assistance
- Must be able to work Monday – Friday 8 - 5 but be flexible with your hours based on business needs to work possible overtime
- Previous experience in the healthcare or medical fields
- Associate's or Bachelor's Degree
- Previous inbound call center or related customer service experience
- 1-3 years of grievance and appeals experience
- Previous experience processing medical claims
- Prior experience with Medicare
- Experience with the Claims Administration System (CAS)
- Knowledge of medical terminology
- Ability to manage large volume of documents including tracking, copying, faxing and scanning
- Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population
Any Humana associate who speaks with a member in a language other than 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 Hours40