Grievances & Appeals Representative 3 (APPEALS only) FULLY BILINGUAL English/Spanish

Description The Bilingual Grievances & Appeals Representative 3 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 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills. How we Value You • Benefits starting day 1 of employment • Competitive 401k match • Generous Paid Time Off accrual • Tuition Reimbursement • Parent Leave • Go365 perks for well-being Responsibilities This role is Remote. You must reside anywhere within Eastern Time Zone Fast growing department with opportunities for growth within the department and company, competitive salary and annual bonus and raises, and a 4% Associate Incentive Plan (AIP) based on company and individual goals and objectives Do you like work with members and providers to investigate and resolve appeals? * Respond to complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and internal processing timelines and guidelines: * Collect, analyze and interpret trend information to address and resolve non-routine business-related concerns Required Qualifications 1 years of experience analyzing and solving customer problems, OR 1 years of work experience in a related environment (i.e. office, administrative, clerical, customer service, etc.) using phones and computers as the primary job tools. 1 years’ experience in the Healthcare industry or Medical field (Production Goal oriented environment). Strong Data entry and Writing skills. Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population. Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. WAH requirements: * Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense. * A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required. * Satellite and Wireless Internet service is NOT allowed for this role. * A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. COVID VACCINATION: Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field. Preferred Qualifications Associate's or Bachelor's Degree highly preferred 1 years of Call Center or High Volume/Metric driven environment. Prior job experience working with assigned cases with specific time-frames to resolve Grievance and Appeals or Utilization Review experience Prior experience with Medicare Additional Information Schedule: Must be able to work Monday – Friday 8:00 am - 5:00 pm, Saturday rotation 8:00 am-5:00 pm. Flexible with your hours based on business needs to work possible overtime. Training: Two month - Remote Grievance & Appeal Assessment: After submitting your application, if you are selected to move forward you will receive an email to complete the Grievance and Appeals Assessment. This is an online activity where you will be asked to answer questions and learn more about Grievance and Appeals jobs at Humana. Most people complete the assessment in 10 to 15 minutes. You can complete the assessment on your phone, tablet or computer (Take your time completing this assessment as it is scored). Your answers will be reviewed and you will subsequently be informed if you will be moving forward to the interview stage. Language Proficiency Testing: Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government. Work Location (Address): Remote from Anywhere with-in Eastern Time Zone #LI-Remote #LI-EM Scheduled Weekly Hours 40