"Alerted.org

Become a part of our caring community and help us put health first

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 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, andworks under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.

Use your skills to make an impact

Required Qualifications

+ 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

Preferred Qualifications

+ 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)

+ 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

Additional Information

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

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

$43,000 - $56,200 per year

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.

About us

About CenterWell Pharmacy: CenterWell Pharmacy provides convenient, safe, reliable pharmacy services and is committed to excellence and quality. Through our home delivery and over-the-counter fulfillment services, specialty, and retail pharmacy locations, we provide customers simple, integrated solutions every time. We care for patients with chronic and complex illnesses, as well as offer personalized clinical and educational services to improve health outcomes and drive superior medication adherence.

About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation’s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first – for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one.

​

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our full accessibility rights information and language options https://www.partnersinprimarycare.com/accessibility-resources