Grievances & Appeals Representative

Puerto Rico

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must have at least 2 years of customer service experience, with a strong preference for experience in the healthcare or medical field. Proficiency in data entry, Microsoft Word, and Excel is required, along with experience in a production-driven environment. Prior experience with Medicare, grievances and appeals, inbound call centers, processing medical claims, and knowledge of medical terminology are preferred. Bilingual skills in English and Spanish are also a plus.

Responsibilities

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

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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