Description

The Grievances & Appeals Professional 2 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skill-sets and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

The Grievances & Appeals Professional 2 assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Required Qualifications

• Bachelor's degree
• Less than 5 years of customer service experience
• Must have experience in the healthcare industry or medical field (Part C)
• Strong data entry skills required
• Advanced experience with Microsoft Word and Excel
• Experience handling multiple projects and assignments as directed by Management
• Capacity to maintain confidentiality and work independently in support of the department
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

• Less than 5 years of grievance and appeals experience
• Strong knowledge in Microsoft Access or experience with SQL Server databases
• Previous experience processing medical claims
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

• This position will work potential weekends and holiday shifts. Hours can vary from 8am-8pm.