Humana · 4 hours ago

Grievances & Appeals Representative 3

Remote Texas

Full-time

Remote

Entry, Mid Level

$40K/yr - $55K/yr

1+ 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.

Performs advanced administrative/operational/customer support duties that require independent initiative and judgment.

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

Investigates and resolves member and practitioner issues.

Decisions are typically focus 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.

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.

Customer service experienceHealthcare industry experienceData entry skillsMicrosoft WordMicrosoft ExcelProduction driven environmentGrievanceAppeals experienceMedical authorizations processingBilingual EnglishBilingual SpanishMedicare experienceClinical Guidance Exchange (CGX 2.0)Medical terminology knowledgeDocument management skills