Humana Grievance and Appeals Representative 3 in Torrance, California
The 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.
The Grievances & Appeals Representative 3 assists members, via phone or face to face, further/support quality related goals.
Investigates and resolves member and practitioner issues.
Decisions are typically focused on methods, tactics and processes for completing administrative tasks/projects.
Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
High School Diploma
1 - 3 years of customer service experience
Must have experience in the healthcare industry or medical field
Prior experience with Medicare
Previous experience processing medical claims
Strong data entry skills required
Intermediate experience with Microsoft Word and Excel
Must have experience in a fast-paced, production driven environment
Case management - ability to prioritize and manage inventory and work flow - strong attention to detail, organizational and time management skills
Department Hours: Must be able to work Thursday- Monday 8 -4:30pm EST based on business needs. Schedule will be centered around Eastern Standard Time hours. Holidays may be required.
Flexibility - ability to work overtime including weekends, based on business needs
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Must ensure designated work area is free from distractions during work hours and virtual meetings
Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required
Associate's or Bachelor's Degree
Less than 2 years of leadership experience
Previous inbound call center or related customer service experience
Previous experience interpreting member benefits
1 - 3 years of grievance and appeals experience
Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
Experience with the Claims Administration System (CAS)
Knowledge of medical terminology
Ability to manage large volume of documents including tracking, copying, faxing and scanning
Excellent interpersonal skills with ability to sensitively and compassionately interact with our members
Scheduled Weekly Hours