Remote Grievances & Appeals Specialist (Medicare Part B)

Humana, Inc.; Dover (DE); Remote; 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

Job summary

Humana, Inc. is seeking a Grievances & Appeals Representative 3 to manage Part B denials and member concerns by conducting analytic review of clinical documentation to determine if a grievance or appeal is warranted.

You will deliver final determination based on trained skillsets and partnerships with clinical and Humana teams. You will perform advanced administrative and customer support tasks with independent initiative and judgment, ensuring adherence to QA metrics and service standards.

Qualifications

• 1+ year of customer service experience.
• Experience in the healthcare industry or medical field.
• 1+ year of grievance and appeals (G&A) experience.

Responsibilities

• Assist members and provider offices by phone.
• Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, dual eligible Medicare/Medicaid, diabetic supply and related claims.
• Follow company and department production goals and QA metrics.
• Make decisions on methods, tactics and processes for completing tasks.
• Exercise discretion prioritizing requests and interpreting procedures.
• Work in a remote/work at home setting with limited guidance.

Skills

Customer service

Healthcare experience

Grievance & Appeals experience

Data entry

Microsoft Word & Excel

Tools

Microsoft Word

Microsoft Excel

Job description

Humana, Inc. is seeking a Grievances & Appeals Representative 3 to manage Part B denials and member concerns by conducting analytic review of clinical documentation to determine if a grievance or appeal is warranted.

You will deliver final determination based on trained skillsets and partnerships with clinical and Humana teams. You will perform advanced administrative and customer support tasks with independent initiative and judgment, ensuring adherence to QA metrics and service standards.