Grievances and Appeals Representative

Become a part of our caring community The Grievances & Appeals Representative 3 manages members and provider PART B denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted. You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties. You will perform advanced administrative and customer support tasks that require independent initiative and judgment. The Grievances & Appeals Representative 3 responsibilities: Assist members and provider offices by phone Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, duel eligible Medicare/Medicaid, diabetic supply and related claims Follow company and department production goals and quality assurance (QA) metrics You will make decisions focused on methods, tactics and processes for completing administrative tasks/projects. You will 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 due Use your skills to make an impact Required Qualifications 1 or more years of customer service (i.e. call center or retail) experience Experience in the healthcare industry, pharmaceutical industry or medical field 1 or more years of grievance and appeals (G&A) experience Experience in a production and quality assurance