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Humana Grievances & Appeals Representative 3 (Bilingual English/Spanish) San Juan, PR in San Juan, Puerto Rico


The Grievances & Appeals Representative 3 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.


The Grievances & Appeals Representative 3 assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions are typically focus on methods, tactics and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.

Required Qualifications

  • High School Diploma or equivalent

  • Bilingual English/Spanish. Candidate selected will not be communicating in English with members. Intermediate/Advance level of communication skills in English

  • 1-3 years of customer service experience

  • 1-3 years prior experience working in a production goal/driven environment

  • Prior job experience working with assigned cases with specific time-frames to resolve

  • Must have experience in the healthcare industry or medical field

  • Strong data entry skills required

  • Intermediate experience with Microsoft Word and Excel

  • Must be able to work Monday - Friday 8 - 5 but be flexible with your hours based on business needs to work possible overtime. On Call on Saturdays and Holidays.

  • Must have critical thinking skills

  • WAH requirements (temporary due to Covid-19 emergency): Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

  • Associate's or Bachelor's Degree

  • Previous inbound call center or related customer service experience

  • 1-3 years of grievance and appeals experience

  • Less than 2 years of leadership experience

  • Previous experience processing medical claims

  • Prior experience with Medicare

  • Experience with the Claims Administration System (CAS)

  • Knowledge of medical terminology

  • Ability to manage large volume of documents including tracking, copying, faxing and scanning

  • Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population

  • Prior experience in health care industry (Health Plan Insurance, Hospital, Pharmacy, etc.)

Additional information


  • G&A Assessment: After submitting your application, if you are selected to move forward you will receive an email to complete the Grievance and Appeals Assessment. This is an online activity where you will be asked to answer questions and learn more about Grievance and Appeals jobs at Humana. Most people complete the assessment in 10 to 15 minutes. You can complete the assessment on your phone, tablet or computer

  • Schedule: Monday to Friday 8am to 5pm, able to do Overtime and flexibility to work on weekends. On Call on Saturdays and Holidays.

  • Training : 3 to 4 weeks - Virtual

  • Work Location (Address ): This permanent job is working from Home temporary due to Covid 19 emergency. This position will deploy to the following location at a future date 383 Ave FD Roosevelt San Juan PR 00918-2131

  • % Travel : 5%

Scheduled Weekly Hours