Quality Audit Professional 2, Grievance and Appeals – Fully Bilingual English, Spanish Employee

Humana

Employee

TELECOMMUTE – MI, IN, KY, TN, GA, FL, OH, NC, SC, WV, VA, PA, DC, CT, NJ, NY, RI, NH, ME, MD, DE, VT

4/29/22

Job Description

Quality Audit Professional 2 (Grievance & Appeals) -(FULLY BILINGUAL English/Spanish) Remote, anywhere with-in Eastern Time Zone

time type: Full time

job requisition id: R-277265

Description

The Quality (Non-Calls) Professional 2 ensures that products meet specific Centers for Medicaid and Medicare Services standards of quality. The Quality (Non-Calls) Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Responsibilities

The Quality Audit Professional 2 audits quality of letter, keyed entries from billing and enrollment data.

Must be bilingual English/Spanish with ability to speak read and write in both languages without limitations or assistance.

Analyze Grievance/Appeals case information to ensure compliance of all CMS regulations and contractual guidelines.

Responsible for the review of written communication provided to members

Reviews case documentation to assess appropriate system entries have been thoroughly completed to mitigate risk associated with external audit reviews.

Responsible for driving accuracy and quality assurance, compliance to all established policies and procedures, and sound documentation for all activities.

Serve as a subject matter expert and make process recommendations.

Checks quality cases built by other associates to ensure highest level of quality.

Follows established guidelines/procedures.

Required Qualifications

2+ years of Grievances & Appeals or Auditing experience in the Healthcare industry

Must be bilingual English/Spanish with ability to speak read and write in both languages without limitations or assistance.

Experience in the Healthcare industry or Medical field (Production Goal oriented environment)

Experience with Medicare and Medicaid

Excellent computer skills and ability to easily navigate multiple applications

Ability to work independently under general instructions and with a team

Work-At-Home Requirements:

WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25×10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

COVID Requirements: For this job, associates are required to be fully COVID vaccinated, including booster or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are ahealthcarecompany committed to putting health and safety first for our members, patients, associates, and the communities we serve.

If progressed to offer, you will be required to:

Provide proof of full vaccination, including boosteror commit to testing protocols OR

Provide proof of applicable exemption including any required supporting documentation

Medical, religious, state and remote-only work exemptions are available.

Preferred Qualifications

Bachelor’s degree

Additional Informa…

Bilingual , Spanish , Insurance , Insurance Claims , Medical & Health , Auditing

MI, IN, KY, TN, GA, FL, OH, NC, SC, WV, VA, PA, DC, CT, NJ, NY, RI, NH, ME, MD, DE, VT