Humana Grievances & Appeals Professional 2- Work at Home- FL in Tampa, Florida
The Grievances & Appeals Professional 2 manages client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The Grievances & Appeals Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Grievances & Appeals Professional 2 (formerly an Analyst role) assists team to further/support quality and compliance related goals. Analyze member/ provider Grievance and Appeals issues.
Coordinating work activities.
Often analyze work of others and/or is the primary administrative owner of a main process, program, product or technology.
Works within broad guidelines with little oversight. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas.
Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
1-3 years of prior grievance and appeals experience
Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the position, you will be required to take a Language Proficiency Assessment in English/Spanish. See Additional Information on testing
Strong analytical skills required
Strong data entry skills required
Experience handling multiple projects and assignments as directed by Management
Attentiveness to detail
WAH requirements: 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
Strong knowledge in Microsoft Access or experience with SQL Server databases
Schedule: Monday to Friday from 8 am to 5 pm, Overtime as needed per business need.
Training: 4 weeks remotely
% Travel: 5
Language Proficiency Testing: Any Humana associate who speaks with a member in a language other than Spanish and/or English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government
Scheduled Weekly Hours