Grievances and Appeals Representative

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

📋 Description

• Oversee member and provider Part B denials and related concerns.

• Perform thorough analytic assessments of clinical documentation.

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

• Provide final determinations leveraging trained expertise and collaborations with clinical and other Humana teams.

• Support members and provider offices via phone communication.

• Investigate and resolve issues faced by members and practitioners regarding Medicare Part B Pharmacy, dual eligible Medicare/Medicaid, diabetic supplies, and related claims.

• Achieve company and departmental production targets and quality assurance standards.

• Make informed decisions about methods, strategies, and procedures for administrative tasks and projects.

• Prioritize incoming requests while interpreting and adapting procedures, processes, and techniques.

• Execute advanced administrative and customer support tasks autonomously.

⛳️ Requirements

• A minimum of 1 year of customer service experience (e.g., call center or retail).

• Background in the healthcare sector, pharmaceutical industry, or medical field.

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

• Familiarity with a production and quality assurance-focused environment.

• Proficient data entry skills, including use of the Microsoft Office suite (Word and Excel).

• Availability to work any day from Sunday to Saturday, in 8-hour shifts between 7 a.m. and 7 p.m. EST.

• Flexibility to work potential overtime based on business requirements.

• A strong commitment to enhancing consumer experiences.

• Previous experience in processing medical claims, particularly Part B Medical Pharmacy claims (preferred).

• Familiarity with Medicare or dual eligible Medicare/Medicaid plans (preferred).

• Knowledge of medical terminology (preferred).

• Experience managing high volumes of documents, including tracking, copying, faxing, and scanning (preferred).

• Proficiency with PaHub for processing medical appeals (preferred).

• Prior experience in a remote/work-at-home setting (preferred).

• Excellent interpersonal skills with a capacity to interact compassionately with the geriatric population (preferred).

• Minimum internet connection of 25 Mbps download and 10 Mbps upload for home-based work.

• A dedicated workspace free from ongoing interruptions to safeguard member PHI/HIPAA information.

🏝️ Benefits

• Medical, dental, and vision insurance.

• 401(k) retirement savings plan.

• Paid time off.

• Company and personal holidays.

• Paid parental and caregiver leave.

• Short-term and long-term disability coverage.

• Life insurance.

• Personal wellness and smart healthcare decision support.

• Occasional travel to Humana's offices for training or meetings may be necessary.