Remote Grievances & Appeals Specialist

Humana; Oregon; Hybrid; USD 43,000 - 56,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement savings plan

Paid time off and holidays

Parental and caregiver leave

Disability and life insurance

Job summary

Humana seeks a Grievances & Appeals Representative 3 to manage member and provider concerns by reviewing clinical documentation and determining whether a grievance or appeal is warranted. You will provide final determinations with collaboration across Humana teams in a remote, home-based role.

You will handle inquiries by phone, investigate Part B Pharmacy and related claims, and strive to meet production and QA goals while prioritizing tasks with independent judgment.

Qualifications

• 1+ year of customer service experience
• Experience in healthcare or medical field
• 1+ year of grievance and appeals experience
• Experience in a production and QA driven environment
• Strong data entry skills including Word and Excel
• Must be able to work 7 a.m.–7 p.m. EST, Sundays–Saturdays, with possible overtime
• Passionate about improving consumer experiences

Responsibilities

• Assist members and provider offices by phone
• Investigate and resolve issues for Medicare Part B Pharmacy and related claims
• Meet production & QA metrics
• Decide methods and processes for administrative tasks/projects
• Prioritize requests and adapt procedures as needed
• Work in a remote/work-at-home setting

Skills

Customer service

Healthcare experience

Grievance & Appeals

Data entry

Microsoft Office

Flexible hours

Tools

PaHub

Job description

Humana seeks a Grievances & Appeals Representative 3 to manage member and provider concerns by reviewing clinical documentation and determining whether a grievance or appeal is warranted. You will provide final determinations with collaboration across Humana teams in a remote, home-based role.

You will handle inquiries by phone, investigate Part B Pharmacy and related claims, and strive to meet production and QA goals while prioritizing tasks with independent judgment.