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  • San Juan, PR

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Grievances & Appeals Representative 3 (FULLY Bilingual, Inbound call center in the Health Care industry, Medicare, Medical Claim

Humana • San Juan, PR

Posted 2 months ago

Job Snapshot

Full-Time
Healthcare - Health Services, Insurance
Health Care, Insurance, Customer Service

Job Description

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.

Job Requirements

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
  • 1-3 years of customer service experience
  • Must have experience in the healthcare industry or medical field
  • Strong data entry skills required
  • Intermediate experience with Microsoft Word and Excel
  • Must have experience in a production driven environment
  • Must be able to work Monday – Friday 8 - 5 but be flexible with your hours based on business needs to work possible overtime
  • 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

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

Additional information

  • 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.

  • 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.
  • Training: 3 to 4 weeks at office
  • Work Location (Address): 383 Ave FD Roosvelt San Juan PR 00918-2131
  • % Travel: 15%
  • HIRING STATUS: Full Time 

Scheduled Weekly Hours

40

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