Humana · 2 days ago

Grievance and Appeals Representative 4

Remote Nationwide

Full-time

Remote

Entry, Mid Level

$43K/yr - $60K/yr

2+ years exp

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Responsibilities

Manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if 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.

Assumes ownership and leads advanced and highly specialized administrative / operational / customer support duties that require independent initiative and judgment.

Assists members via phone to further / support quality related goals.

Reviews the level 1 appeals cases and ensures that information is correct and then forwards to CMS entity for further review.

Investigates and resolves member and practitioner issues.

Decisions are regarding the daily priorities for an administrative work group and/or external vendors including coordinating work activities and monitoring progress towards schedules/goals and is the primary administrative owner of a main process, program, product, or technology.

Works within broad guidelines with little oversight.

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Grievance & Appeals experienceCustomer service experienceData entry skillsMicrosoft WordMicrosoft ExcelProduction driven environmentElectronic inventory managementInbound call center experienceCAS experienceMedHOK experienceProcessing medical claimsTime management skills