Quality non-calls Professional 2/Quality Audit/Grievance amp Appeals FULLY BILINGUAL English/Spanish Miami FL

Profile

Description

The Quality (Non-Calls) Professional 2 ensures that products meet certain standards of quality. The Quality (Non-Calls) Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Quality Audit Professional 2 audits quality of letter, keyed entries from billing and enrollment data.

Analyze Grievance/Appeals case information to ensure compliance of all CMS regulations and contractual guidelines.

Responsible for the review of written communication provided to members and providers.

Reviews case documentation to assess appropriate system entries have been thoroughly completed to mitigate risk associated with external audit reviews and ensure the highest level of quality.

Responsible for driving accuracy, quality assurance, and compliance to all established policies and procedures, as well as sound documentation for all activities.

Serve as a subject matter expert and make process recommendations.

Follows established guidelines/procedures.

Required Qualifications

HS Diploma

2 years of Grievance & Appeals and/or Auditing experience in the Healthcare Industry.

Excellent computer skills and ability to easily navigate multiple applications

Ability to work independently under general instructions and with a team

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

Preferred Qualifications

Bachelor's degree

Experience with Medicare and Medicaid

Additional Information

Schedule: Monday through Friday between the hours of 8:00 AM-5:00 PM ET. Occasional Overtime to meet business needs.

Training: If the associate is internal and has G&A knowledge, then training can be about 1-2 months. Otherwise the training period can be 2-3 months. This includes on-the-job training.

Work Location (Address): This permanent job is working from Home temporary due to Covid 19 emergency. This position will deploy to the following location at a future date: 11430 NW 20th St, Suite 300, Miami, FL 33172

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.

Scheduled Weekly Hours

40

Company info

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