Grievances and Appeals Specialist

3 weeks ago

Marquand, Missouri, United States Humana Full time
About the Role

We are seeking a highly skilled and detail-oriented Grievances and Appeals Representative to join our team at Humana. As a key member of our healthcare operations team, you will play a critical role in ensuring that our customers receive the best possible care and service.

Key Responsibilities
  • Manage client medical denials by conducting a comprehensive review of clinical documentation to determine if an appeal is warranted.
  • Perform advanced administrative and customer support duties that require independent initiative and judgment.
  • Apply intermediate mathematical skills and exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques.
  • Work under limited guidance and take ownership of your work, ensuring high-quality results and timely completion of tasks.
Requirements
  • 2+ years of experience working with customers in a fast-paced, deadline-oriented environment.
  • Experience with prioritizing and managing inventory and workflow.
  • Customer-focused, analytical, and decision-making skills, with the ability to work well under minimal supervision and take initiative.
  • Strong technical skills, with the ability to work across multiple software systems and a comfort level with working remotely.
  • High level of emotional intelligence, with a proven ability to influence office culture and engagement in a positive manner.
Preferred Qualifications
  • Associate's or Bachelor's Degree.
  • Prior experience interpreting Member Benefits and Medical Claims.
  • Humana's operating systems: MHK (MedHok), CCP/GCP/CAS, CI, CGX.
  • Medicare experience.
  • Experience with CMS Guidelines and remaining compliant.
  • Bilingual (English and Spanish) with the ability to read, write, and speak both languages.
About Humana

Humana is a leading healthcare company that is committed to putting health first for our teammates, customers, and communities. We make it easier for the millions of people we serve to achieve their best health, delivering the care and service they need, when they need it.

We are an equal opportunity employer and welcome applications from diverse candidates. We are committed to creating a workplace that is inclusive and respectful of all employees, and we strive to provide opportunities for growth and development for all our teammates.

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