[Remote] Grievances & Appeals Representative at Humana

Wisconsin, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Candidates must have a minimum of two years of customer service experience and prior experience in the healthcare or medical industry. Proficiency with Microsoft Office, including Outlook, Excel, and PowerPoint, is required, along with strong data entry skills and the ability to adhere to process maps. Experience in a fast-paced, production-oriented environment, with proven ability to prioritize tasks and manage workflow, is essential. Candidates must possess robust technical skills for working from home, including navigating multiple software systems, and have a distraction-free workspace with reliable internet service (minimum 25 Mbps download, 10 Mbps upload). An Associate's or Bachelor's degree is preferred, as is previous inbound call center or grievance and appeals experience, experience with Medicare, and knowledge of medical terminology.

Responsibilities

The Grievances & Appeals Representative 3 will manage client denials and concerns by conducting analytic reviews of clinical documentation to determine if a grievance, appeal, or further request is warranted. They will deliver final determinations based on trained skillsets and partnerships with clinical and other Humana parties. This role involves assisting members and providers via phone or written communication to investigate and resolve inquiries, applying intermediate mathematical skills as needed. The representative will exercise discretion and judgment in prioritizing requests and interpreting procedures, processes, and techniques to complete administrative tasks and projects.

Skills

Customer Service

Healthcare

Data Entry

Microsoft Office

Outlook

Excel

PowerPoint

Process Adherence

Prioritization

Workflow Management

Analytical Skills

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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