[Remote] Grievances & Appeals Representative at Humana

Kentucky, United States

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Not SpecifiedCompensation

Entry Level & New GradExperience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Minimum of 1 year of customer service experience
Minimum of 1 year of data entry experience
Experience in a production driven environment
Virtual training will start on day one and be Monday – Friday, 8 am – 4:30 pm EST
Following training, must be able to work an 8-hour shift, 5 days/week, Sunday through Saturday between 8am EST to 7pm EST (shift assigned during training)
Must reside in Central or Eastern Standard Time Zone (CST or EST)
Self-provided internet service must meet minimum criteria: download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable or DSL suggested; satellite, cellular, or microwave only if approved)
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Responsibilities

Perform thorough reviews of clinical documentation to assess whether grievances, appeals, or additional requests are justified, and provide final determinations utilizing expertise and collaboration with clinical and other Humana teams
Assign cases to team members for submission to an independent entity for 2nd level review
Monitor and record the number of cases assigned to the team, as well as the distribution of cases among individual associates
Operate within established guidelines to maintain work expectations and quality standards, while exercising discretion in prioritizing tasks and managing timelines with minimal supervision
Demonstrate flexibility and resilience in adapting to evolving processes and a fast-paced work environment

Skills

Key technologies and capabilities for this role

customer servicedata entrygrievancesappealsclinical documentation reviewmedical terminologyMedHokPaHubService Read Onlymedical claims processinginbound call center

Questions & Answers

Common questions about this position

Is this a remote position?

Yes, this is a remote work-from-home position, but candidates must reside in the Central or Eastern Standard Time Zone (CST or EST).

What are the required qualifications for this role?

The role requires a minimum of 1 year of customer service experience, 1 year of data entry experience, and experience in a production-driven environment.

What are the work hours and shift requirements?

Virtual training starts on day one, Monday–Friday 8am–4:30pm EST. After training, you must work an 8-hour shift, 5 days/week, Sunday through Saturday between 8am EST to 7pm EST, with the shift assigned during training.

What preferred qualifications would make me a stronger candidate?

Preferred qualifications include an associate or bachelor's degree, experience with MedHok, PaHub, Service Read Only, medical claims processing, grievance and appeals, medical terminology, bilingual English/Spanish skills, Medicare experience, and Claims Administration System (CAS).

What is the salary or compensation for this position?

This information is not specified in the job description.

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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