Grievances & Appeals Representative

Humana Inc. is committed to putting health first for their customers and teammates. The Grievances & Appeals Representative 3 manages client denials and concerns by reviewing clinical documentation and delivering final determinations, while also performing advanced administrative and customer support duties. Responsibilities 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 skillsets and/or partnerships with clinical and other Humana parties Performs advanced administrative/operational/customer support duties that require independent initiative and judgment Assists members, via phone or face to face, further/support quality related goals Investigates and resolves member and practitioner issues Decisions are typically focus 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 Skills 1 - 3 years of customer service experience Less than 2 years of leadership experience Must have experience in the healthcare industry or medical field Strong data entry skills required Intermediate experience with Microsoft Word and Excel Must have experience in a production driven environment Must be able to work Monday – Friday 8 - 5 but be flexible with your hours based on business needs to work possible overtime Previous experience in the healthcare or medical fields Must be passionate about contributing to an organization focused on continuously improving consumer experiences Associate's or Bachelor's Degree Previous inbound call center or related customer service experience 1 - 3 years of grievance and appeals experience Previous experience processing medical claims Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish Prior experience with Medicare Experience with the Claims Administration System (CAS) and MHK 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 geriatric population Benefits 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 Company Overview Humana is a health insurance provider for individuals, families, and businesses. It was founded in 1964, and is headquartered in Louisville, Kentucky, USA, with a workforce of 10001+ employees. Its website is