Grievances & Appeals Representative

Become a part of our caring community and help us put health first
 Do you enjoy helping those in need? Do you love researching, analyzing medical documents to determine if something was missed? Have you ever considered yourself a detective for medical claims / member benefits?
Well, if you answered yes to any of the above you may be a great fit for Humana’s Grievances & Appeals Representative 3 role!

What we need your help with:

• Managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
• Perform advanced administrative and/or customer support duties that require independent initiative and judgment.
• From time to time apply intermediate mathematical skills and regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques.
• Work under limited guidance at the comfort of your home due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.

Use your skills to make an impact
 

We are only considering candidates who live within 50 miles of one of the following locations:

• Louisville, KY
• Tampa, FL
• San Antonio, TX
• Green Bay, WI
• San Juan, PR 

Required Qualifications

• 2+ years working with customers in a fast-paced, deadline-oriented environment 
• Experience with the ability to prioritize and manage inventory and workflow 
• Customer focused, analytical and decision-making skills — works well under minimal supervision and takes initiative
• Strong technical skills with the ability to work across multiple software systems and comfortable work remote out of your home 
• High level of emotional intelligence with a proven ability to influence office culture and engagement in a positive manner

Required Work Schedule: 

Training/Nesting:

Virtual training runs for 7-8 weeks with a schedule of 8:00am – 4:30pm EST, Monday – Friday.

• Please note that training is a critical stage of associate development. Attendance is vital for your success, so no time off, other than observed holidays, is allowed during training.
• New Hire Training requires you to be appropriately dressed, on time and on camera via the facilitated Zoom classroom instruction for attendance.
• After Training and Nesting you will be assigned to another supervisor and Team Lead within the department

 Work Hours:

Your shift will coincide with the department business hours of 8:00am to 4:30pm EST, Monday – Friday.

• PTO is not available in the first 120 days of employment. You will accrue PTO and can use it after the first 120 days.
• Mandatory Overtime and business need for inventory, may include weekend days and holidays.  Hours are subject to change based on business needs but are always communicated ahead of the need.
• 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.

Preferred Qualifications

• Associate’s or Bachelor’s Degree
• Prior experience interpreting Member Benefits and Medical Claims 
• Humana’s operating systems: MHK (MedHok), CCP/GCP/CAS, CI, CGX
• Medicare experience
• Experience with CMS Guidelines and remaining compliant
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish. 

Additional Information

Please be sure to include your resume with your application! 

Work From Home:

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 recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Employees 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 employees 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.

$40,200 - $55,200 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.