Grievances amp Appeals Representative 4 FULLY BILINGUAL English/Spanish Remote - Eastern Time Zone

Profile

Description

The Grievances & Appeals Representative 4 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative 4 assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties that require independent initiative and judgment.

Responsibilities

The Grievances & Appeals Representative 4 assists members, via phone or face to face, further/support quality related goals.

Investigates and resolves member and practitioner issues.

Decisions are regarding the daily priorities for an administrative work group and/or external vendors including coordinating work activities and monitoring progress towards schedules/goals, and often oversees work of others and/or is the primary administrative owner of a main process, program, product or technology.

Works within broad guidelines with little oversight.

Manages client medical denials by conducting a comprehensive analytic review of clinical documentation to assist with the process of working of an appeal.

Assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties that require independent initiative and judgment

Required Qualifications

1 years of leadership experience

1 years of customer service experience

Fully Bilingual English/Spanish . Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. See Additional Information on testing

Strong data entry skills

Must have experience in the Healthcare Industry or Medical Field.

Intermediate experience with Microsoft Word and Excel

Must have experience in a production driven environment

WAH requirements:

Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

COVID VACCINATION : 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.

Preferred Qualifications

1 year Inbound Call Center experience

1 year experience Processing Medical Claims

Associate's or Bachelor's Degree

1 years of grievance and appeals experience

Additional information

Schedule: Monday to Friday from 8 am to 5 pm but be flexible with your hours based on business needs to work possible overtime

Training: 6 WEEKS Virtual Training

Work Location (Address): Remote anywhere within Easter time zone

Travel: 25% for UPS drop off

Language Proficiency Testing: Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

#LI - Remote

#LI-EM1

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com