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The Senior Grievances & Appeals Analyst/Professional analyzes and audits complaints received by the plan to ensure the integrity of claims, authorization processes, and business operations. You will report to the Associate Director, Grievances and Appeals, and be a part of the Resolution team.
As a Senior Grievances & Appeals Professional, you will:
- Analyze and audit complaints received by the plan to ensure the integrity of claims, authorization processes, and business operations.
- Utilize established process guidelines and industry knowledge to validate organizational decisions and assess downstream and upstream impacts.
- Perform root cause analysis of audit findings and make recommendations for appropriate change management.
- Emphasize continuous improvement by identifying opportunities to reduce redeterminations, complaints, and rework of claims.
- Identify trends and areas of improvement resulting from information obtained through the Resolution team resources and available reporting/data.
Use your skills to make an impact
Required Qualifications
- 5 or more years of healthcare services experience in Sales, enrollment, Complaints to Medicare (CTMs).
- 1 or more years auditing experience.
- Experience using data analysis tools (such as Excel, SQL, or Power Bi) to create and analyze reports to identify trends.
- Demonstrated knowledge using advanced features in Microsoft Excel, including data sorting, pivot tables, and complex formulas.
- Experience managing concurrent projects, maintaining thoroughly documented outcomes and minimal data entry error rates.
Preferred Qualifications
- Bachelor's degree.
- Experience with claims or authorization experience.
Additional Information
- Work schedule: 8 am to 5pm EST.
- HireVue: As part of our hiring process, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability.
- Work at Home: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service must meet specific criteria (minimum 25 Mbps download / 10 Mbps upload).
- Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
- Scheduled Weekly Hours: 40.
- Pay Range: $65,000 - $88,600 per year. This job is eligible for a bonus incentive plan.
Description of Benefits
Humana offers competitive benefits that support whole-person well-being, including medical, dental and vision benefits, 401(k) retirement savings plan, time off, disability, life insurance, and more.
About us
Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. #LI-BB1