Grievances and Appeals Representative

Become a part of our caring community The Grievances & Appeals Representative 3 manages members and provider denials and concerns through conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted. You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties. You will perform advanced administrative and customer support tasks that require independent initiative and judgment. The Grievances & Appeals Representative 3 responsibilities: Assist members and provider offices by phone Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, duel eligible Medicare/Medicaid, diabetic supply and related claims Follow company and department production goals and quality assurance (QA) metrics You will make decisions focused on methods and processes for completing administrative tasks/projects. You will exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques Work in a remote/work at home setting under limited guidance Use your skills to make an impact Required Qualifications 1 or more years of customer service (i.e. call center or retail) experience Experience in the healthcare industry, pharmaceutical industry or medical field 1 or more years of grievance and appeals (G&A) experience Experience in a production and quality assurance driven setting Strong data entry skills including the Microsoft office suite (Word and Excel) Must be able to work Sunday – Saturday, between the hours of 8 a.m. - 7 p.m. EST, but adaptable with your hours based on business needs to work possible overtime Must be passionate about contributing to an organization focused on continuously improving consumer experiences Preferred Qualifications Previous experience processing medical claims (Ideally Part B Medical Pharmacy claims) Experience with Medicare or dual eligible Medicare/Medicaid plans Knowledge of medical terminology Experince managing large volume of documents including tracking, copying, faxing and scanning Experience with PaHub (For processing medical appeals) Prior experience working in a remote/work at home environment Excellent interpersonal skills with the ability to sensitively and compassionately talk with geriatric population Additional Information Work Hours: Sunday – Saturday, between the hours of 8 a.m. - 7 p.m. EST, but be flexible with your hours based on business needs to work possible overtime Work Style: Remote Work at Home/Remote Requirements To ensure Hybrid Office/Home associates' ability to work effectively, the self-provided internet service of Hybrid Office/Home 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 Home or Hybrid Home/Office associates with telephone and computer equipment appropriate to meet the business requirements for their position/job Work from a dedicated space lacking ongoing interruptions to protect member