Grievances and Appeals Representative

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

📋 Description

• Oversee member and provider denials as well as concerns.

• Execute thorough analytic assessments of clinical documentation.

• Assess whether a grievance, appeal, or additional request is necessary.

• Provide final decisions through collaboration with clinical teams and other Humana stakeholders.

• Undertake advanced administrative and customer support responsibilities autonomously.

• Support members and provider offices via phone communication.

• Investigate and resolve issues related to Medicare Part B Pharmacy, dual eligible Medicare/Medicaid, diabetic supplies, and associated claims for both members and practitioners.

• Adhere to company and departmental production objectives and quality assurance standards.

• Make decisions concerning methods and processes for administrative tasks and projects.

• Prioritize requests and interpret or modify procedures, processes, and techniques as needed.

⛳️ Requirements

• A minimum of 1 year of experience in customer service, including call center or retail roles.

• Background in the healthcare, pharmaceutical, or medical sectors.

• At least 1 year of experience in grievance and appeals (G&A) processes.

• Experience in environments focused on production and quality assurance.

• Proficient data entry skills, particularly with the Microsoft Office suite (Word and Excel).

• Availability to work 8-hour shifts on Friday, Saturday, and Sunday between 7 a.m. and 5 p.m. EST.

• Flexibility to adjust working hours based on business requirements.

• A strong commitment to enhancing consumer experiences continuously.

• Minimum home internet speed of 25 Mbps for downloads and 10 Mbps for uploads.

• Capability to work from a designated area without interruptions to ensure the protection of member PHI / HIPAA information.

🏝️ Benefits

• Medical benefits

• Dental benefits

• Vision benefits

• 401(k) retirement savings plan

• Paid time off

• Company holidays

• Personal holidays

• Paid parental leave

• Paid caregiver leave

• Short-term disability

• Long-term disability

• Life insurance

• Personal wellness support

• Smart healthcare decision support

• Occasional travel to Humana offices for training or meetings