Grievances & Appeals Representative IV

Description

The Grievances & Appeals Representative IV 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 IV assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties that require independent initiative and judgment.

Responsibilities

The Grievances & Appeals Representative IV:

• 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.

This is a remote role 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.  Holiday work may be required, however is only mandatory based on business needs.

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.
• Department Hours: Must be able to work any 8-hour shift from Monday through Friday. Hours range between 8am-9pm EST Monday – Thursday, with a minimum schedule of 10am-6:30pm EST on Friday
• Training will start day one of employment and run the first 6-8 weeks with a schedule of 8:00 am – 4:30 pm EST. Attendance is vital for success so no time off is allowed during training
• Weekend work required on rotating basis, 9am-5:30pm, based on business need
• Overtime and Holiday work may be required based on business need. Voluntary overtime may also be available
• Minimum 1 year 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

Work-At-Home Requirements

• 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

Preferred Qualifications

• Undergraduate Degree
• Experience with electronic inventory management - able to complete assigned cases in a specified timeframe
• Inbound call center or related Customer Service experience
• CAS and MedHOK experience strongly preferred
• Previous experience processing medical claims

Additional Information

• As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.
• If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews. #LI-Remote

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 decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

 

$43,400 - $59,600 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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.