Grievances & Appeals Representative - Humana
Dover, DE
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 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.
The Grievances & Appeals Representative 4:
+ Assists members and supports quality related goals.
+ A successful associate reviews the level 1 appeals cases and ensures that information is correct and then forwards all documentation to CMS review entity Maximus Federal Services for further review.
+ They are expected to resolve member and practitioner issues to the best of their ability.
+ 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.
Use your skills to make an impact
Required Work Schedule :
Training :
+ Virtual Training will start day one of employment and runs the first 6-8 weeks with a schedule of 8:00am-4:30pm EST, Monday - Friday.
+ Attendance is vital for success, so no time off is allowed during training or within your first 120 days, with the exception of observed (and paid) company holidays.
Work Schedule :
+ Must be able to work any 8-hour shift Monday-Thursday between 8:00am and 9:00pm EST. With a minimum schedule of 10:00am-6:30pm EST on Friday.
+ Weekend work required on rotating basis, 9:00am-5:30pm EST based on business needs. A 5% shift differential will be added for working a weekend.
+ Overtime and Holiday work may be required, however is only mandatory based on business needs. Voluntary overtime may also be available.
+ Grievances 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.
Required Qualifications
+ Minimum 1 year of Grievance & Appeals and/or relevant customer service experience
+ Strong data entry skills required
+ Intermediate experience with Microsoft Word and Excel
+ Must have experience in a production driven environment
+ Experience handling multiple projects and assignments as directed by Management
+ Capacity to maintain confidentiality and work independently in support of the department
Preferred Qualifications
+ Associate's or Bachelor's Degree
+ Experience with electronic inventory management - able to complete assigned cases in a specified time frame
+ Previous inbound call center or related customer service experience
+ CAS and MedHOK experience strongly preferred
+ Previous experience processing medical claims
+ Medicare experience
Work at Home Guidance
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.
As part of our hiring process for this opportunity, we will be using an 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. If you are selected for a first-round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate in a HireVue interview. In this interview, you will listen to a set of interview questions over your phone, and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.
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 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.
The Grievances & Appeals Representative 4:
+ Assists members and supports quality related goals.
+ A successful associate reviews the level 1 appeals cases and ensures that information is correct and then forwards all documentation to CMS review entity Maximus Federal Services for further review.
+ They are expected to resolve member and practitioner issues to the best of their ability.
+ 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.
Use your skills to make an impact
Required Work Schedule :
Training :
+ Virtual Training will start day one of employment and runs the first 6-8 weeks with a schedule of 8:00am-4:30pm EST, Monday - Friday.
+ Attendance is vital for success, so no time off is allowed during training or within your first 120 days, with the exception of observed (and paid) company holidays.
Work Schedule :
+ Must be able to work any 8-hour shift Monday-Thursday between 8:00am and 9:00pm EST. With a minimum schedule of 10:00am-6:30pm EST on Friday.
+ Weekend work required on rotating basis, 9:00am-5:30pm EST based on business needs. A 5% shift differential will be added for working a weekend.
+ Overtime and Holiday work may be required, however is only mandatory based on business needs. Voluntary overtime may also be available.
+ Grievances 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.
Required Qualifications
+ Minimum 1 year of Grievance & Appeals and/or relevant customer service experience
+ Strong data entry skills required
+ Intermediate experience with Microsoft Word and Excel
+ Must have experience in a production driven environment
+ Experience handling multiple projects and assignments as directed by Management
+ Capacity to maintain confidentiality and work independently in support of the department
Preferred Qualifications
+ Associate's or Bachelor's Degree
+ Experience with electronic inventory management - able to complete assigned cases in a specified time frame
+ Previous inbound call center or related customer service experience
+ CAS and MedHOK experience strongly preferred
+ Previous experience processing medical claims
+ Medicare experience
Work at Home Guidance
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.
As part of our hiring process for this opportunity, we will be using an 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. If you are selected for a first-round interview, you will receive an email correspondence (please be sure to check your spam or junk folders often to ensure communication isn't missed) inviting you to participate in a HireVue interview. In this interview, you will listen to a set of interview questions over your phone, and you will provide recorded responses to each question. You should anticipate this interview to take about 15 to 30 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.
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