Grievances and Appeals Representative

Become a part of our caring community

The Grievances & Appeals Representative 3 (Part Time 24 hours a week) manages members and provider denials and concerns through conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted. You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties. You will perform advanced administrative and customer support tasks that require independent initiative and judgment.
The Grievances & Appeals Representative 3 responsibilities:

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Assist members and provider offices by phone

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Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, duel eligible Medicare/Medicaid, diabetic supply and related claims

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Follow company and department production goals and quality assurance (QA) metrics

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You will make decisions focused on methods and processes for completing administrative tasks/projects.

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You will exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques

- Work in a remote/work at home setting

Use your skills to make an impact

Required Qualifications

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1 or more years of customer service (i.e. call center or retail) experience

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Experience in the healthcare industry, pharmaceutical industry or medical field

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1 or more years of grievance and appeals (G&A) experience

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Experience in a production and quality assurance driven setting

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Strong data entry skills including the Microsoft office suite (Word and Excel)

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Can work 8 hour shifts on Friday, Saturday and Sunday between the hours of 7 a.m. - 5 p.m. EST, but adaptable with your hours based on our needs

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Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

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Previous experience processing medical claims (Ideally Part B Medical Pharmacy claims)

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Experience with Medicare or dual eligible Medicare/Medicaid plans

- Knowledge of medical terminology

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Experience managing large volume of documents including tracking, copying, faxing and scanning

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Experience with PaHub (For processing medical appeals)

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Prior experience working in a remote/work at home environment

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Experience building relationships with the ability to sensitively and compassionately talk with geriatric population

Additional Information

Schedule :

- Friday, Saturday and Sunday

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8 hour shifts between the hours of 7 a.m. - 5 p.m. Eastern Standard Time (EST)

- Part Time 24 hours a week

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Must be flexible with your hours based on our needs

Work Style : Remote
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours
24 Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$43,000 - $56,200 per year Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”)