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

　　The Grievances & Appeals Representative 4 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 4 assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties that require independent initiative and judgment.

　　The Grievances & Appeals Representative 4 assists members via phone to further/support quality related goals. Reviews the level 1 appeals cases and ensures that information is correct and then forwards to CMS entity for further review. Investigates and resolves member and practitioner issues.

　　Decisions are regarding the daily priorities for an administrative work group and/or external vendors including coordinating work activities and monitoring progress towards schedules/goals and is the primary administrative owner of a main process, program, product, or technology.

　　Works within broad guidelines with little oversight.

　　Use your skills to make an impact

　　Required Qualifications

　　Minimum 1 year of Grievance & Appeals and/or customer service experience

　　Strong data entry skills required

　　Intermediate experience with Microsoft Word and Excel

　　Must have experience in a production driven environment

　　Experience handling multiple projects and assignments as directed by Management

　　Capacity to maintain confidentiality and work independently in support of the department

　　Required Work Schedule :

　　This position can be in office or work at home in EST or CST and will provide coverage for eastern time zone hours. Weekend work required - based on a rotation and business needs.

　　Training :

　　Virtual Training will start day one of employment and runs the first 6-8 weeks with a schedule of 8:00am-4:30pm EST, Monday - Friday.

　　Attendance is vital for success, so no time off is allowed during training or within your first 120 days, with the exception of observed (and paid) company holidays.

　　Work Schedule :

　　Must be able to work any 8-hour shift Monday-Thursday between 8:00 am and 9:00 pm EST. With a minimum schedule of 10:00 am EST - 6:30 pm EST on Friday.

　　Weekend work required on rotating basis, 9:00am-5:30pm based on business needs.

　　Overtime and Holiday work may be required, however is only mandatory based on business needs. Voluntary overtime may also be available.

　　Grievances and Appeals (G&A) has an impact to our business and because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18 months.

　　Preferred Qualifications

　　Associate's or Bachelor's Degree

　　Experience with electronic inventory management - able to complete assigned cases in a specified time frame.

　　Previous inbound call center or related customer service experience

　　CAS, MedHOK experience strongly preferred

　　Previous experience processing medical claims

　　Additional Information

　　Please be sure to include your resume with your application!

　　As part of our hiring process for this opportunity, we will be using an interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule!

　　Work From Home:

　　To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

　　At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

　　Satellite, cellular and microwave connection can be used only if approved by leadership

　　Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

　　Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.

　　Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

　　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 decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$43,400 - $59,600 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

　　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

　　Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

　　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 because he or she is a protected veteran. It is also the policy of  Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.

　　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 https://www.humana.com/legal/accessibility-resources?source=Humana_Website.