[Remote] Grievances & Appeals Representative at Humana

Kentucky, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess at least 2 years of customer service experience and experience in the healthcare or medical field. Strong data entry skills, intermediate proficiency in Microsoft Word and Excel, and experience in a production-driven environment are required. Preferred qualifications include an Associate's or Bachelor's degree, prior Medicare experience, 1+ years of grievances and appeals experience, previous inbound call center or customer service experience, experience processing medical claims, bilingual English/Spanish skills, experience with Claims Administration System (CAS) and MHK (MedHOK), and knowledge of medical terminology.

Responsibilities

The Grievances & Appeals Representative manages client denials and concerns by conducting analytic reviews of clinical documentation to determine if a grievance, appeal, or further request is warranted. They deliver final determinations based on trained skillsets and/or partnerships with clinical and other Humana parties. This role involves assisting members via phone or face-to-face, investigating and resolving member and practitioner issues, and contributing to quality-related goals. The representative exercises discretion and judgment in prioritizing requests and interpreting procedures, processes, and techniques.

Skills

Customer Service

Healthcare Industry

Medical Field

Data Entry

Microsoft Word

Microsoft Excel

Production Environment

Grievance Management

Appeals Management

Clinical Documentation Review

Problem-Solving

Communication

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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