Grievances & Appeals Rep - IRT
Core
Manage Level 1 appeal cases by reviewing clinical documentation to determine if further action is needed and validate final determinations for Humana members.
Role type
Senior IC grievance and appeals representative
Builds
Appeal determinations and resolution outcomes for Medicare/Medicaid members
Domain
US Healthcare Insurance / Claims Appeals
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Grievance and appeals case management, Clinical documentation review, CMS compliance adherence, Data entry, Microsoft Office proficiency, Multi-tasking in production environments
Preferred skills
Medical claims processing, Inbound call center experience, CAS and MedHOK systems, Inventory management
Responsibilities
Manage Level 1 appeal cases ensuring accuracy and CMS compliance, Review clinical documentation to support appeal determinations, Coordinate with clinical teams to finalize outcomes, Investigate and resolve member and provider issues, Maintain high productivity in a production-driven environment, Independently prioritize and manage high-volume case assignments