Grievances & Appeals Representative

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The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. You will perform advanced administrative/operational/customer support responsibilities that require independent initiative and judgment.

+ Assist members by phone to further/support quality related goals.
+ Investigate and resolve member and practitioner issues.
+ Decisions 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.
+ Work independently with limited supervision, drawing on substantial exper...

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