Humana
Description
The Bilingual Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties.
Responsibilities
- Assists members and providers to investigate and resolve appeals
- Conduct outreach attempts to providers to obtain all necessary documents to prepare case file for decision
- Prepare and present cases in G&A workgroup to medical directors and other department management team for decision
Required Qualifications
- 1 or more years of experience in a healthcare and customer service
- Experience in a production driven environment
- Strong data entry skills
- Experience with Microsoft Word & Excel
- Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish.
Preferred Qualifications
- 1-3 years of grievance and appeals experience
- Prior experience with Medicare
Additional Information
Schedule: Monday-Friday 8AM-5PM Eastern Standard Time; overtime per business needs.
Work-At-Home Requirements
- WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
- A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.
- Satellite and Wireless Internet service is NOT allowed for this role.
- A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information