Job Description & Responsibilities:
The Appeals Representative 4 is responsible for managing appeal denials, by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partner. You will report to a Supervisor, Grievances & Appeals. As the Appeals Representative 4 you will. Managed Level 1 appeal cases, ensuring accuracy, completeness, and compliance with CMS requirements. Reviewed clinical documentation to support appeal determinations and escalation decisions. Coordinated with clinical teams and internal partners to finalize appeal outcomes. Investigated and resolved member and provider issues with a focus on resolution. Maintained high productivity and quality standards in a production-driven environment. Ensured strict adherence to confidentiality and compliance regulations Independently prioritized and managed multiple high-volume case assignments. Embrace change and support smooth transitions in work environment.
Qualifications:
Required Qualifications: 1 or more years of Grievance & Appeals experience. Strong data entry skills. 1 or more years with Outlook (email and calendar management), Excel (data entry), Word (creating and editing documents) and Teams (meetings, chat, and file sharing). Preferred Qualifications: Associate Degree or higher. 2 or more years of Grievance & Appeals experience. Medical claims processing experience. Previous inbound call center/customer service experience. Experience with CAS and MedHOK. Inventory management experience.
Salary:
$48,300 - $65,900 per year
Contact:
Employer: Humana
Link: https://careers.humana.com/us/en/job/R-423151/Appeals-Rep