Associate Director Grievances and Appeals FULLY Bilingual English/Spanish Remote within Eastern time zone

Profile

Description

The Associate Director, Grievances & Appeals 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 Associate Director, Grievances & Appeals requires a solid understanding of how organization capabilities interrelate across department(s).

Responsibilities

The Associate Director, Grievances & Appeals assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions are typically related to identifying and resolving complex technical and operational problems within department(s), andcould lead multiple managers or highly specialized professional associates.

Required Qualifications


Bachelor's Degree or Equivalent job experience ( 5 years)
5 years of Management experience
Strong knowledge of CMS Appeals regulations
Must have relevant experience in the healthcare industry or medical field
Advanced experience with Microsoft Word and Excel
Demonstrate critical and independent thinking
Experience handling multiple projects and assignments as directed by Management
Capacity to maintain confidentiality and work independently in support of the department
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
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
Work At Home requirements : Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required. 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


Lean Six Sigma Certified
Previous experience with delivering presentations to Senior Leaders
Nursing LPN or RN license


Additional Information


Schedule: Monday to Friday from 8 am to 5 pm. Overtime as per business needs.
Training: 8 weeks of virtual training
Work Location (Address): Work at Home EASTERN TIME ZONE LOCATIONS
% Travel: 20% Tampa for meetings, or to other States for training .
# of Direct Reports :7 for now but this number may change.
Language Proficiency Testing (English/Spanish): 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. Strong verbal and written communication skills


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Scheduled Weekly Hours

40

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our ****

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