3 jobs found in Dover, remote

The Capture Lead, Medicaid Clinical and Population Health Strategy, will lead initiatives to develop and execute strategy to successfully position Humana to capture growth opportunities. This role will work horizontally across the organization, coordinating with Medicaid leadership and clinical subject matter experts to synthesize, assess, and translate state requirements into actionable go-to-market clinical strategy. The Lead will consult with growth partners to design and optimize clinical operating model blueprints for viable Medicaid health plans that meet the needs of state clients and populations served in target growth markets. Responsibilities Humana Healthy Horizons is seeking an exceptional candidate to join our Medicaid Product Strategy Organization to advance Humana’s Medicaid products and capabilities and support the strategic direction and growth of the Medicaid and Duals lines of business. This is a unique opportunity for a motivated individual to...

The Vendor Management Oversight team is committed to effective and efficient Utilization Management solutions for Humana’s Medicare and Medicaid operational business. We are in search for a Vendor Management Professional to work as liaison between UM vendors and the organization. The Vendor Management Professional performs varied activities and moderately complex administrative/operational/member and/or provider escalations. The Vendor Management Professional work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Responsibilities The Vendor Management Professional reviews terms of vendor contracts and communicates with vendors regarding day-to-day matters. Builds and maintains positive relationship with vendors and monitor vendor performance holding the vendor accountable for meeting performance goals to ensure the vendor is meeting contractual requirements and expected timelines for...

The Bilingual Grievances & Appeals Representative 3 manages client concerns by conducting and responding to complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and internal processing timelines. Collect, analyze, and interpret trend information to address and resolve non-routine business-related concerns. Responsibilities Bilingual Grievances & Appeal Representative 3 Reviewing customer complaints Outreach to providers and members Customer conflict resolution Conflict prevention Required Qualifications 1 or more years of experience in a telephonic customer service environment Strong data entry skills Experience with Microsoft Word, Excel & Outlook Fully Bilingual English/Spanish. Must be able to speak, read and write in both languages without limitations or assistance. If selected for the...