Grievances and Appeals Representative

About the role

Become a part of our caring community The Grievances & Appeals Representative 3 (Part Time 24 hours a week) manages members and provider denials and concerns through conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted. You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties. You will perform advanced administrative and customer support tasks that require independent initiative and judgment.

Responsibilities

• Assist members and provider offices by phone
• Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, dual eligible Medicare/Medicaid, diabetic supply and related claims
• Follow company and department production goals and quality assurance (QA) metrics
• Make decisions focused on methods and processes for completing administrative tasks/projects
• Exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques
• Work in a remote/work‑at‑home setting

Requirements

• 1+ years of customer service experience (call center or retail)
• Experience in the healthcare, pharmaceutical, or medical field
• 1+ years