Grievances & Appeals Representative

1 week ago
Ohio, OH, United States Humana Full-time

Become a part of our caring community
Become a valued member of Humana's Internal Review Team as a Grievances & Appeals Representative 2, where you will play a critical role in addressing client concerns and denials. You will perform thorough reviews of clinical documentation to assess whether grievances, appeals, or additional requests are justified. Then, you will 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. Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Key Responsibilities:

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


Use your skills to make an impact

Required Qualifications

  • Minimum of 1 year of customer service experience
  • Minimum of 1 year of data entry experience
  • Experience in a production-driven environment
  • Must have strong experience using multiple Microsoft systems simultaneously (Teams, SharePoint, Excel, etc.)
  • Ability to manage large volume on inventory daily

Preferred Qualifications

  • 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

Additional Information

  • Workstyle: remote, work from home
  • Work Location: must reside in Central or Eastern Standard Time Zone (CST or EST)
  • Training schedule: Monday-Friday, 8am-4:30pm EST
  • Shift after training: Wednesday-Sunday schedule.
    • The Wednesday-Friday shifts are 9am-5:30pm EST
    • The Saturday-Sunday shifts are 8am-4:30pm EST
  • Grievances and Appeals (G&A) has an impact to our business and because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18-months.
Work at Home Requirements: 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 required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.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 health

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