Do you enjoy helping those in need? Do you love researching, analyzing medical documents to determine if something was missed? Have you ever considered yourself a detective for medical claims / member benefits? Well, if you answered yes to any of the above, you may be a great fit for Humana’s Grievance & Appeals Representative 3 role!

Responsibilities

The Grievance & 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 Grievance & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

What you need for success!

Required Qualifications:

• 2+ years working with customers in a fast-paced, production-driven, deadline-oriented environment.
• Experience in the healthcare industry or medical field; knowledge of medical terminology.
• Ability to work overtime, including weekends and holidays, based on business needs.
• Previous inbound call center or related customer service experience
• Experience with the ability to prioritize and manage inventory and workflow. Ability to manage large volume of documents including tracking, copying, faxing and scanning.
• Customer-focused, analytical, sound decision making skills. Works well under minimal supervision and takes initiative.
• Strong data entry / technical skills with the ability to work across multiple software systems and comfortable working remotely from home.
• Intermediate experience with Microsoft Word and Excel.
• High level of emotional intelligence with a proven ability to influence culture and engagement in a positive manner. Excellent interpersonal skills with ability to sensitively and compassionately interact with our members. Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Required Work Schedule:

• Virtual Training will start day one of employment and runs for 8 - 10 weeks with a schedule of 8:00 am – 4:30 pm EST, Monday - Friday. Attendance is vital for success, so no time off – with the exception of observed company holidays - is allowed during training.

• Following training, must be available to work any shift between the hours of 8:00 am - 6:00 pm EST, Monday – Friday. Hours are subject to change based on business needs.

• Mandatory Overtime may include weekend days and holidays, based on business needs.

• No time off during the first 120 day appraisal period.

• Must commit to working within the department for minimum of eighteen (18) months.

• May need to occasionally come into the local office.

**LOCATION**

Seeking candidates in the following locations only:

• Kentucky
• Indiana
• Ohio
• Florida
• Wisconsin
• Puerto Rico (50 mile range of San Juan, PR)

Preferred Qualifications:

• Associate's or Bachelor's Degree
• Experience with Humana’s Claims Administration and operating systems: MHK (MedHok), CCP/GCP/CAS, CI, CGX
• 1 - 3 years of grievance and appeals experience
• Bilingual in English and Spanish with the ability to read, write and speak English and Spanish.

Work at Home Guidance

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 Home or Hybrid Home/Office 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.

Covid-19 Vaccine Policy

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field. Every associate and contractor who work inside a Humana facility or in the field, regardless of vaccination status, must complete a daily health screening questionnaire.

Additional Information

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected for a first round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn’t missed) inviting you to participate in a Modern Hire interview. In this interview, you will listen to a set of interview questions over your phone and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

#LI-REMOTE

Scheduled Weekly Hours

40