[Hiring] Grievances & Appeals Representative @Humana

Role Description

The Grievances and Appeals Representative 4 role in the Internal Review Team is responsible for managing appeal denials, by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partners.

• Manage Level 1 appeal cases, ensuring accuracy, completeness, and compliance with CMS requirements
• Review clinical documentation to support appeal determinations and escalation decisions
• Coordinate with clinical teams and internal partners to finalize appeal outcomes
• Investigate and resolve member and provider issues with a focus on timely resolution
• Maintain high productivity and quality standards in a production-driven environment
• Ensure strict adherence to confidentiality and compliance regulations
• Independently prioritize and manage multiple high-volume case assignments
• Proactively embraces change and supports smooth transitions in a dynamic work environment

Qualifications

• 1+ year of grievance & appeals and/or customer service experience
• Strong data entry skills
• Proficiency in Microsoft Office Applications
• Experience in a production-driven environment
• Experience prioritizing and delivering multiple assignments
• Strong commitment to confidentiality and high-quality results

Requirements

• Training: Monday-Friday, 8am-4:30pm EST your first 4-6 weeks.
• Shift after training: Candidates must be flexible and able to work a variety of shifts, between the hours of 7am-7pm, including weekends.
• Overtime and holiday work may be required based on business needs.
• Time off requirement: To support a strong onboarding experience, time off is generally not scheduled during training or within the first 120 days of employment.
• Work at Home Requirements: Minimum download speed of 25 Mbps and upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
• Scheduled Weekly Hours: 40
• Pay Range: $48,300 - $65,900 per year

Benefits

• Medical, dental and vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• Short-term and long-term disability
• Life insurance
• Many other opportunities