Grievances & Appeals Representative

Grievances & Appeals Representative

Become a part of our caring community and help us put health first. Become a valued member of Humana's Internal Review Team as a Grievances & Appeals Representative, where you will play a critical role in addressing client concerns and denials. In this position, you will perform thorough reviews of clinical documentation to assess whether grievances, appeals, or additional requests are justified, and provide final determinations utilizing your expertise and collaboration with clinical and other Humana teams. Your contributions will directly support Humana's commitment to delivering high-quality service and making a positive difference in the lives of those we serve.

Assigns cases to team members for submission to an independent entity for 2nd level review. Monitors and records the number of cases assigned to the team, as well as the distribution of cases among individual associates. Operates within established guidelines to maintain work expectations and quality standards, while exercising discretion in prioritizing tasks and managing timelines with minimal supervision. Demonstrates flexibility and resilience in adapting to evolving processes and a fast-paced work environment.

Required Qualifications

Minimum of 1 year of customer service experience. Minimum of 1 year of data entry experience. Experience in a production driven environment. Virtual training will start on day one and be Monday Friday, 8 am 4 : 30 pm EST. Following training, candidates must be able to work an 8-hour shift, 5 days / week, Sunday through Saturday between 8am EST to 7pm EST. Shift will be assigned during training.

Preferred Qualifications

Associate or bachelor's degree. Previous experience with MedHok, PaHub, and / or Service Read Only. Previous experience in medical claims processing. Previous inbound call center or related customer service experience. Previous grievance and appeals experience. Medical terminology experience. Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish. Prior experience with Medicare. Experience with the Claims Administration System (CAS). Ability to manage large volume of inventory.

Additional Information

Workstyle : remote, work from home. Work Location : must reside in Central or Eastern Standard Time Zone (CST or EST). Must be able to work an 8-hour shift, 5 days / week, Sunday through Saturday between 8am EST to 7pm EST.

To ensure Home or Hybrid Home / Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home / Office employees 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. Employees 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 employees 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.

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. 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 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. $40,000 - $52,300 per year

Description of Benefits Humana, 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.

About us Humana Inc. (NYSE : HUM) is committed to putting health first for our teammates, our customers and our company. Through our Humana insurance services and 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. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.