[Remote] Grievances & Appeals Representative at Humana

Kentucky, United States

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Not SpecifiedCompensation

Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

2+ years of customer service experience
Experience in the healthcare industry or medical field
Strong data entry skills
Intermediate experience with Microsoft Word and Excel
Experience in a production driven environment
Passionate about contributing to an organization focused on continuously improving consumer experiences
Ability to work Monday–Friday, 8am-5pm EST, with flexibility for overtime and weekends based on business needs
No time off during initial 5-week training or first 120 days
18-month commitment to the Grievances & Appeals department
Self-provided internet meeting minimum speeds (25 Mbps download, 10 Mbps upload recommended; wireless, wired cable or DSL suggested)
Work from a dedicated space lacking ongoing interruptions to protect PHI/HIPAA information

Responsibilities

Manage client denials and concerns by conducting comprehensive analytic review of clinical documentation to determine if a grievance, appeal, or further request is warranted
Deliver final determination based on trained skillsets and/or partnerships with clinical and other Humana parties
Perform advanced administrative/operational/customer support duties requiring independent initiative and judgment
Apply intermediate mathematical skills as needed
Assist members via phone or face-to-face to support quality-related goals
Investigate and resolve member and practitioner issues
Exercise discretion and judgment in prioritizing requests, interpreting and adapting procedures, processes, and techniques
Work under limited guidance due to experience and knowledge of administrative processes and organizational knowledge

Skills

Customer Service

Healthcare

Data Entry

Microsoft Word

Microsoft Excel

Grievances

Appeals

Clinical Documentation

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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