[Remote] Grievances & Appeals Representative at Humana

Wisconsin, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Minimum of two years of customer service experience
Experience working in the healthcare field and/or medical industry
Excellent data entry capabilities
Proficiency with Microsoft Office, including intermediate skills in Outlook, Excel, and PowerPoint
Ability to adhere to process maps
Experience working in a fast-paced, production-oriented environment
Proven ability to prioritize tasks and manage inventory and workflow
Strong focus on customer service, with keen analytical and decision-making abilities
Robust technical skills
Availability of a distraction-free workspace at home
Minimum download speed of 25 Mbps and upload speed of 10 Mbps internet connection

Responsibilities

Manage client denials and concerns by conducting a comprehensive analytic review of clinical documentation
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
Assist members, via phone or face to face, further/support quality related goals
Investigate and resolve member and practitioner issues
Prioritize requests and interpret and adapt procedures, processes and techniques
Work under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge
Set up and connect a computer with additional monitors
Navigate multiple software systems and applications simultaneously
Work from home
Work possible overtime, weekends and holidays based on business needs

Skills

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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