[Hiring] Grievances & Appeals Expedited Triage Rep @Humana

Role Description

Become a part of our caring community. The Grievances & Appeals Representative 2 triages Medicaid and AIP (dual) expedited cases and determines if a grievance or appeal is warranted by reviewing clinical documentation. This is an extremely high-volume, fast-paced role, with the responsibility of moving several cases per hour. We ask that you have proactive queue management, attention to changing processes, experience handling support requests across multiple workstreams, and effective communication with managers and team leads.

• Review and evaluate several cases per hour by identifying valid expedited Medicaid and AIP (dual) cases. Caseload volume varies; this is a significant high-volume role.
• Recognize urgent vs. routine cases and meet strict turnaround expectations (15–30 minutes).
• Conduct analytic reviews of clinical documentation to determine case validity, including investigative work to find the denial.
• Make outbound calls to members or providers to verbally acknowledge receipt of valid cases.
• Work closely with leadership, who will assign cases to appropriate team contacts once your investigations are complete and validity is determined.
• 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 the 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 metrics
• Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems
• Demonstrated ability to manage 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 experience with grievance and appeals (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

• Competitive benefits that support whole-person well-being
• 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

Company Description

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it.