Grievances amp Appeals Professional 2 - Bilingual English/Spanish Exp. GampA cases in the Health Care Industry Remote FL ONLY

Profile

Description

The Grievances & Appeals Professional 2 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities


The Grievances & Appeals Professional 2 (formerly an Analyst role) assists team to further/support quality and compliance related goals. Analyze member/ provider Grievance and Appeals issues AND ASSIGNS ACCORDINGLY.
Often analyze 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. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.


Required Qualifications


1 year experience working with Grievance and Appeals cases within the Health Care Industry (Health Insurance- Preferred).
Strong analytical skills required
Strong data entry skills required
Experience handling multiple projects and assignments as directed by Management
Attentiveness to detail
Excellent time management skills and ability to work independently
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. 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 Requirements : 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


Bachelor's Degree


Additional Information


Schedule: Monday to Friday from 8 am to 5 pm, Overtime as needed per business need.
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
Training : 2 Month remotely.
Work Location (Address): Remote from Florida ONLY
Travel: 5%


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Scheduled Weekly Hours

40

Company info

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