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Grievance and Appeals Representative 3

Humana

Location: Tampa, FL 33603
Type: Non-Remote
Posted on: November 23, 2020
This job is no longer available from the source.
**Description** The Grievances & 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 Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills. **Responsibilities** + The Grievances & Appeals Representative 3 assists members, via phone or face to face, further/support quality related goals. + Investigates and resolves member and practitioner issues. + Decisions are typically focused on methods, tactics and processes for completing administrative tasks/projects. + Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge. **Required Qualifications** + High School Diploma + 1 - 3 years of customer service experience + Must have experience in the healthcare industry or medical field + Prior experience with Medicare + Previous experience processing medical claims + Strong data entry skills required + Intermediate experience with Microsoft Word and Excel + Must have experience in a fast-paced, production driven environment + Case management - ability to prioritize and manage inventory and work flow - strong attention to detail, organizational and time management skills + Department Hours: Must be able to work Thursday- Monday 8 -4:30pm EST based on business needs. **Schedule will be centered around Eastern Standard Time hours. Holidays may be required.** + Flexibility - ability to work overtime including weekends, based on business needs + Must be passionate about contributing to an organization focused on continuously improving consumer experiences + Must ensure designated work area is free from distractions during work hours and virtual meetings + Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required **Preferred Qualifications** + Associate's or Bachelor's Degree + Less than 2 years of leadership experience + Previous inbound call center or related customer service experience + Previous experience interpreting member benefits + 1 - 3 years of grievance and appeals experience + Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish + Experience with the Claims Administration System (CAS) + Knowledge of medical terminology + Ability to manage large volume of documents including tracking, copying, faxing and scanning + Excellent interpersonal skills with ability to sensitively and compassionately interact with our members **Scheduled Weekly Hours** 40 <>
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