The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an 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.
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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 focused 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.
Required Qualifications
- High School Diploma
- 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
- 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 work flow – strong attention to detail, organizational and time management skills
- Department Hours: Must be able to work Thursday– Monday 8 -4:30pm EST based on business needs. Schedule will be centered around Eastern Standard Time hours. Holidays may be required.
- Flexibility – ability to work overtime including weekends, based on business needs
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- Must ensure designated work area is free from distractions during work hours and virtual meetings
- Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10×1 (10mbs download x 1mbs upload) for optimal performance of is required
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 sensitively and compassionately interact with our members
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