Grievances and Appeals Representative 4

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.

This position can be in office or work at home in EST or CST and will provide coverage for eastern time zone hours. Weekend work required - based on a rotation and business needs with 5% Shift differential for working a weekend.

What you need for success! Required Qualifications

• 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.

• Must be able to work an 8 hour shift from Monday through Friday
  • Any time between 8am-9am EST Monday – Thursday, 10am-6:30pm EST Friday, with Weekends required on rotating basis Saturday, 9am-2pm based on business needs; with overtime required as needed. Holiday work may be required as well
• 100% attendance is required in training; 8am to 4:30pm EST Monday – Friday; no time off is allowed
• 1 years of grievance and appeals and/or customer service experience
• Strong data entry skills required
• Intermediate experience with Microsoft Word and Excel
• Must have experience in a production driven environment
• Must be passionate about contributing to an organization focused on continuously improving consumer experience
• Experience handling multiple projects and assignments as directed by Management
• Capacity to maintain confidentiality and work independently in support of the department

What you need to STAND OUT in the crowd! 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

Additional Information

• 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, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities.

These requirements include access to a personal computing device with a camera, a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes.