**Description** The Grievances & Appeals Representative 3 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. 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 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills. + Assists members, via phone or written correspondence, 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. **What we need your help with:** + Manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. + Perform advanced administrative and/or customer support duties that require independent initiative and judgment. + From time to time, apply intermediate mathematical skills and regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques. + Work under limited guidance at the comfort of your home due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge. COME GROW WITH HUMANA! BENEFITS DAY ONE - STELLAR 401K MATCH - PAID TIME OFF **Required Qualifications** + 1 - 3 years of customer service experience + 1- 3 years of Medicaid or Medicare experience + 1- 3 years of Grievance & Appeals and/or medical claims processing experience + Must have experience in the healthcare industry or medical field + Strong data entry skills required + Intermediate experience with Microsoft Word and Excel + Strong written and verbal communication skills + Must have experience in a fast-paced, production driven environment + Case management - ability to prioritize and manage inventory and workflow - strong attention to detail, organizational and time management skills + Schedule for this position is 8:00am -- 5:00pm EST Monday- Friday based on business needs with holiday and Saturday rotations as needed. + 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 Work-At-Home Requirements + 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 + Must commit to working within the department for minimum of eighteen (18) month **Preferred Qualifications** + Associates or Bachelor's Degree + Previous inbound call center or related customer service experience + Previous experience interpreting member benefits + 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 **Additional Information** **Training:** Humana offers virtual training for the first 4-6 weeks following start. Attendance is required for your success. **Scheduled Weekly Hours** 40 <>
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