Grievances and Appeals 3

San Antonio, Texas, United States

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Not SpecifiedCompensation

Junior (1 to 2 years), Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Candidates require 1-3 years of customer service experience, less than 2 years of leadership experience, and experience in the healthcare or medical field. Strong data entry skills, intermediate Microsoft Word and Excel proficiency, and experience in a production-driven environment are necessary. The role requires flexibility with work hours, including potential overtime, and a passion for improving consumer experiences.

Responsibilities

The Grievances & Appeals Representative 3 manages client denials and concerns by conducting thorough analytic reviews of clinical documentation to determine if a grievance, appeal, or further request is warranted, and then delivers a final determination. This role performs advanced administrative and operational duties requiring independent initiative and judgment, potentially applying intermediate mathematical skills. Responsibilities include assisting members via phone or in person, supporting quality-related goals, investigating and resolving member and practitioner issues, and prioritizing requests while adapting procedures and processes under limited guidance.

Skills

Customer Service

Data Entry

Microsoft Word

Microsoft Excel

Healthcare Industry

Medical Field

Production Environment

Call Center

Problem-Solving

Analytical Review

Decision Making

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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