Remote Medicare Grievances & Appeals Specialist

Humana, Inc.; Salem (OR); Remote; USD 43,000 - 56,000; Full time

Job summary

Humana, Inc. is seeking a Grievances & Appeals Representative 3 to support members and providers remotely. You will review clinical documentation, determine if grievances or appeals are warranted, and deliver final determinations in coordination with clinical teams and Humana stakeholders.

This full-time role requires healthcare industry experience, strong data entry skills, and the ability to work 7 a.m.–7 p.m. EST on Sundays through Saturdays, with potential overtime.

Qualifications

• 1+ years of customer service experience.
• Experience in healthcare/pharma/medical field.
• 1+ years of grievances and appeals experience.
• Experience in a production/QA driven environment.
• Strong data entry skills including Word and Excel.
• Must be able to work any day Sunday – Saturday, 8-hour shifts between 7 a.m. - 7 p.m. EST, with possible overtime.
• Must be passionate about contributing to an organization focused on improving consumer experiences.

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 focused on methods, tactics and processes for completing administrative tasks/projects.
• Exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques.
• Work in a remote/work at home setting under limited guidance.

Skills

Customer service

Healthcare exp

G&A experience

Data entry

Microsoft Office

Job description

Humana, Inc. is seeking a Grievances & Appeals Representative 3 to support members and providers remotely. You will review clinical documentation, determine if grievances or appeals are warranted, and deliver final determinations in coordination with clinical teams and Humana stakeholders.

This full-time role requires healthcare industry experience, strong data entry skills, and the ability to work 7 a.m.–7 p.m. EST on Sundays through Saturdays, with potential overtime.