Bilingual Grievance & Appeals Quality Audit Professional
DescriptionThe Bilingual Quality (Non-Calls) Professional 2 conducts a comprehensive analytic review of member grievances.
The Bilingual Quality Audit Professional 2 audits quality of letter, keyed entries from billing and enrollment data.
Analyze Grievance 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.
Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. See Additional Information on testing
1 or more years of working Grievances and/or Appeals
Advanced experience with Microsoft Word and Excel
1 or more years working in a production based environment with daily metrics
Experience with Medicare and Medicaid
1 or more years of experience with CMS guidelines
1 or more years of Auditing experience
Monday-Friday, 8am-5pm EST with Overtime to meet the needs of the business
As part of our hiring process, we will be using an exciting interviewing technology provided by Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Language Proficiency Testing
Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.
Work at Home Guidance
To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested
Satellite, cellular and microwave connection can be used only if approved by leadership
Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Internal- If you have additional questions regarding this role posting, please send them to the Ask A Recruiter persona by visiting go/yammer and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.
Alert: Humana values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide their social security number, if it is not already on file. When required, an email will be sent from [email protected] with instructions on how to add the information into your official application on Humana’s secure website.
Scheduled Weekly Hours40
Pay RangeThe compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$47,700 - $65,600 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of BenefitsHumana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.