The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

Responsibilities

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.

Benefits and Perks of This Opportunity:

• Competitive compensation with strong hourly rate and bonus eligibility
• Extensive 100% virtual training program for the first 5 weeks setting you up for immediate and future success.
• Robust benefits as a full-time employee including health, dental, vision, tuition assistance, 401(k) and more. Effective first day – no waiting period!
• Professional development opportunities including career advancement and mobility, virtual learning platforms, networking opportunities through our network resource groups, mentoring programs and more

We are only considering candidates who live within 50 miles of one of the following locations:

• Louisville, KY
• Tampa, FL
• San Antonio, TX
• Green Bay, WI
• San Juan, PR

Work Schedule (Post training): Must work an 8-hour shift between the hours of 10:30 a.m. – 7 p.m. EST Tuesday through Saturday with overtime based on business need

Training Schedule: 5-week training Monday – Friday 8:30 a.m. to 4:00 p.m. EST - Attendance is vital for success, there is no time off allowed during training

**PLEASE MAKE SURE YOU ATTACH YOUR RESUME TO YOUR APPLICATION (pdf or Word format) **

Required Qualifications

• Must live within 50 miles of any of the following locations: Louisville, KY; Tampa, FL; San Antonio, TX; Green Bay, WI; San Juan, PR
• Position and training are Remote but are expected to visit/attend the office 1 to 2x/year
• 1 - 3 years of customer service experience
• Must have experience in the healthcare industry or medical field
• Prior experience with Medicare
• Previous experience processing medical claims
• Strong data entry skills required
• Strong communication skills both written and verbal
• Intermediate experience with Microsoft Word and Excel
• Must have experience in a fast-paced, production driven environment
• Case management - ability to prioritize and manage inventory and workflow - strong attention to detail, organizational and time management skills
• Must meet all Work at home (WAH) requirements
• Must operate all work and training schedules on EST
• Work Schedule (Post training): Must work an 8-hour shift between the hours of 10:30 a.m. – 7 p.m. EST Tuesday through Saturday with overtime based on business need
• Training Schedule: 5-week training Monday – Friday 8:30 a.m. to 4:00 p.m. EST
• Attendance is vital for success, there is no time off allowed during training
• Must commit to working within the department for minimum of eighteen (18) months

Preferred Qualifications

• Associate's or Bachelor's Degree
• Less than 2 years of leadership experience
• Previous inbound call center or related customer service experience
• Previous experience interpreting member benefits
• 1 - 3 years of grievance and appeals experience
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• 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 interact with our members sensitively and compassionately

Work at Home Requirements

• To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership.
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

**PLEASE MAKE SURE YOU ATTACH YOUR RESUME TO YOUR APPLICATION (pdf or Word format) **

Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information to the application at Humana’s secure website.

Additional Information

Steps for this job:

• Prescreen: Shortly after submitting your application, you will receive both a text message and email requesting you to complete 10 to 15 prescreen questions with either yes or no answers. The text message may arrive prior to the email. If you prefer to answer via computer or tablet, wait for the email.
• Assessment: If the prescreen is passed, you will receive another communication to take the Grievances and Appeals Assessment. This is an online activity where you will see a Realistic Job Preview to learn more about the job and then be asked to answer questions where 30 minutes should be set aside to complete. You can complete the assessment on your phone, tablet or computer; however, most candidates prefer using a computer or tablet.
• Interviews: Some candidates will be invited to interview. If so, the recruiter will reach out to schedule. A writing sample may or may not be required.
• Offers: Finalists from the interview will be contacted by the recruiter to discuss an offer for the job
• Note: Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed.

This is a remote position

#LI-Remote

Scheduled Weekly Hours

40