Grievance & Appeals Rep

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The Grievances & Appeals Representative 3 manages client denials and concerns. We do this by conducting a comprehensive analytic review of clinical documentation to determine if an appeal, grievance, or further request is warranted. Then, the representative delivers a final determination based on trained skillsets or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support tasks that require independent initiative and judgment.
The Grievances & Appeals Representative 3 assists members, by phone or face-to-face, further/support quality related goals. Investigate and resolve member and practitioner issues. Decisions are typically focus on methods and tactics for completing administrative tasks/projects. Exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works due ...