Grievance & Appeals Representative

This is a fully remote position, open to applicants in United States.

📋 Description

• Provide assistance to members and providers regarding grievance and appeal inquiries

• Investigate and address concerns raised by members and practitioners

• Record interactions and ensure detailed documentation is maintained

• Clarify processes, policies, and outcomes of resolutions

• Conduct research and compile information to facilitate case resolutions

• Implement departmental policies and procedures within assigned tasks

• Manage workload effectively and prioritize tasks to meet service expectations

• Work collaboratively with internal teams to tackle complex issues

• Forward concerns that necessitate further review or action

• Assist in achieving quality, compliance, and member experience objectives

• Execute thorough analytic reviews of clinical documentation to assess the necessity of grievances, appeals, or additional requests

• Provide final decisions based on acquired skillsets and collaborations with clinical and other Humana teams

• Engage in administrative tasks, operational support, customer assistance activities, and calculations

⛳️ Requirements

• Prior experience in customer service

• Background in the healthcare sector or medical field

• Familiarity with a production-driven work environment

• Intermediate proficiency in Microsoft Word and Excel

• Availability to work an 8-hour shift from Monday to Friday, between 8 a.m. and 8 p.m.

• Willingness to work overtime as needed by the business

• Capability to work from a dedicated space, ensuring no interruptions to maintain member PHI/HIPAA confidentiality

• Access to self-provided internet service with a minimum of 25 Mbps download and 10 Mbps upload speeds

• Commitment to enhancing consumer experiences through continuous improvement

• Associate's or Bachelor's Degree is preferred

• Experience in medical claims processing is preferred

• Previous inbound call center or similar customer service experience is preferred

• 1–3 years of experience in grievances and appeals is preferred

• Knowledge of medical terminology is preferred

• Bilingual proficiency in English and Spanish is preferred

• Prior experience with Medicare is preferred

• Familiarity with the Claims Administration System (CAS) is preferred

• Understanding of medical terminology is preferred

• Ability to handle large volumes of documents, including tracking, copying, faxing, and scanning is preferred

• Strong interpersonal skills with the ability to engage sensitively and compassionately with the geriatric population is preferred

🏝️ Benefits

• Medical, dental, and vision coverage

• 401(k) retirement savings plan

• Paid time off

• Company holidays

• Personal holidays

• Paid parental leave

• Paid caregiver leave

• Short-term disability benefits

• Long-term disability coverage

• Life insurance

• Opportunities to support holistic well-being and informed healthcare choices

• Remote work option