Grievances & Appeals Representative 4 - Humana
Augusta, ME
About the Job
Become a part of our caring community and help us put health first
The Grievances & Appeals Representative 4 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 4 assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties that require independent initiative and judgment.
Where you Come In
The Grievances & Appeals Representative 4 assists members, 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.
What Humana Offers
We are fortunate to offer a remote opportunity for this job. Our Fortune 100 Company values associate engagement & your well-being. We also provide excellent professional development & continued education.
Use your skills to make an impact
Required Qualifications - What it takes to Succeed
+ Minimum of 2 years' experience with Code Edit
+ Minimum of 1 year experience in G & A
+ Must have experience in a production driven environment
+ Strong data entry skills required
+ Strong proficiency with Microsoft Word and Excel
+ Works within broad guidelines with little oversight
+ Must be able to work an 8 hour shift from Monday through Friday
+ Weekends required on rotating basis (also some holidays as needed)
+ Grievance and Appeals (G&A) has an impact to our business and because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18-months
+ This position can be in office or work at home and will provide coverage for eastern time zone hours.
Preferred Qualifications
+ CAS and MedHOK experience strongly preferred
+ Experience with electronic inventory management - able to complete assigned cases in a specified time frame
+ Previous inbound call center or related customer service experience
+ Previous experience processing medical claims
+ Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
Additional Information - How we Value You
* Benefits starting day 1 of employment
* Competitive 401k match
* Generous Paid Time Off accrual
* Tuition Reimbursement
* Parent Leave
Work at Home Requirements
* To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
* At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
* Satellite, cellular and microwave connection can be used only if approved by leadership
* Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
* Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
* Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Interview Format
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Scheduled Weekly Hours
40
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.$43,400 - $59,600 per year
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
The Grievances & Appeals Representative 4 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 4 assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties that require independent initiative and judgment.
Where you Come In
The Grievances & Appeals Representative 4 assists members, 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.
What Humana Offers
We are fortunate to offer a remote opportunity for this job. Our Fortune 100 Company values associate engagement & your well-being. We also provide excellent professional development & continued education.
Use your skills to make an impact
Required Qualifications - What it takes to Succeed
+ Minimum of 2 years' experience with Code Edit
+ Minimum of 1 year experience in G & A
+ Must have experience in a production driven environment
+ Strong data entry skills required
+ Strong proficiency with Microsoft Word and Excel
+ Works within broad guidelines with little oversight
+ Must be able to work an 8 hour shift from Monday through Friday
+ Weekends required on rotating basis (also some holidays as needed)
+ Grievance and Appeals (G&A) has an impact to our business and because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18-months
+ This position can be in office or work at home and will provide coverage for eastern time zone hours.
Preferred Qualifications
+ CAS and MedHOK experience strongly preferred
+ Experience with electronic inventory management - able to complete assigned cases in a specified time frame
+ Previous inbound call center or related customer service experience
+ Previous experience processing medical claims
+ Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
Additional Information - How we Value You
* Benefits starting day 1 of employment
* Competitive 401k match
* Generous Paid Time Off accrual
* Tuition Reimbursement
* Parent Leave
Work at Home Requirements
* To ensure Home or Hybrid Home/Office associates' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
* At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
* Satellite, cellular and microwave connection can be used only if approved by leadership
* Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
* Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
* Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Interview Format
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Scheduled Weekly Hours
40
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.$43,400 - $59,600 per year
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Source : Humana