[Hiring] Grievances & Appeals Expedited Case Rep @Humana

Role Description

The Grievances & Appeals Representative 3 works expedited Medicaid and AIP (dual) appeals cases and reviews clinical documentation to determine if an appeal is warranted. This is an extremely high-volume, fast-paced role, with the responsibility of moving several cases per hour.

• Review and evaluate several expedited Medicaid and AIP (dual) cases per hour. Caseload volume varies as it is a consistently significant high-volume role.
• Manage cases from assignment to resolution, conducting analytic reviews of clinical documentation and collaborating with business partners to complete investigations.
• Assess case urgency and process cases in chronological order, ensuring resolution within strict turnaround times (typically 24 hours).
• Make outbound calls on every case to deliver outcome to members or providers, or request documentation, clarify case details or address outstanding issues.
• Stay current with frequently changing mentor documents and workflows.
• Monitor multiple workstreams and adapt quickly to process changes.
• Communicate gaps or issues and seek guidance as needed.

Qualifications

• Must live in Central or Eastern time zone
• 1+ years of customer service experience
• 1+ years of experience in the healthcare industry or medical field
• Must have experience with production and meeting performance metrics
• Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems
• Experience managing a high-volume, rapidly changing workload while remaining self-sufficient, managing shifting priorities, and adapting to new processes without disruption

Requirements

• Associate or bachelor's Degree (Preferred)
• Previous inbound call center or related customer service experience (Preferred)
• Prior Grievances and Appeals experience (Preferred)
• Previous experience processing medical authorizations (Preferred)
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish (Preferred)
• Prior experience with Medicare or Medicaid (Preferred)
• Knowledge of medical terminology (Preferred)

Benefits

• 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
• Many other opportunities

Required Training Schedule

Beginning June 29th, virtual training will start day one and will last for approximately four (4) weeks. Training will be held Monday through Friday and will follow a schedule between 8:00 am – 5:00 pm (Central or Eastern Time). Attendance is vital for success; no time off is allowed during training and is limited within the first 180 days.

Required Work Schedule

Following training, must be able to work 11:30 am – 8:00 pm (in your CST/EST time zone), Tuesday through Saturday, with alternating holidays and overtime as needed. Hours are subject to change based on business needs. Must commit to working within the department for a minimum of eighteen (18) months.

Work at Home Guidance

• Minimum internet service requirements: download speed of 25 Mbps and an upload speed of 10 Mbps recommended.
• Associates who live and work from Home in the state of 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.
• Occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The 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 will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$43,000 - $56,200 per year

Application Deadline

05-17-2026