Appeals Rep

About the role

As the Appeals Representative 4, you will manage appeal denials by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partners. You will report to a Supervisor, Grievances & Appeals.

Responsibilities

• 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 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.
• Embrace change and support smooth transitions in the work environment.

Requirements

• 1 or more years of Grievance & Appeals experience.
• Strong data entry skills.
• 1 or more years of experience with Outlook (email and calendar management), Excel (data entry), Word (creating and editing documents), and Teams (meetings, chat, and file sharing).

Preferred Qualifications

• Associate Degree or higher.
• 2 or more years of Grievance & Appeals experience.
• Medical claims processing experience.
• Previous inbound call center/customer service experience.
• Experience with CAS and MedHOK.
• Inventory management experience.

Schedule

This is a remote role providing coverage for Eastern time zone hours.

• Training: Virtual training starts on day one of employment and runs for the first 6-8 weeks with a schedule of 8:00 AM - 4:30 PM EST, Monday - Friday.
• Work Schedule: Following training, hours range from 7:00 AM - 7:00 PM EST. Workdays may vary between Sunday through Saturday based on workforce management needs.
• Must be flexible and able to work a variety of shifts, including weekends.
• Availability to work on Saturdays and Sundays may be required based on business needs.
• Candidates must accommodate schedule changes based on business needs.
• Overtime and holiday work may be required based on business needs.

Work at Home Requirements

• Self-provided internet service must meet the following criteria: minimum download speed of 25 Mbps and upload speed of 10 Mbps; wireless, wired cable, or DSL connection is suggested. Satellite, cellular, and microwave connections may be used only if approved by leadership.
• Employees in California, Illinois, Montana, or South Dakota will receive a bi-weekly payment for internet expenses.
• Humana will provide telephone equipment appropriate for business requirements.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information.
• Humana reserves the right to require associates to upgrade their internet service if necessary for business needs.

Travel

While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Pay

The pay range for this full-time (40 hours per week) position is $48,300 - $65,900 per year. The range may be higher or lower based on geographic location, and individual pay will vary based on demonstrated job-related skills, knowledge, experience, education, and certifications.

Benefits

Humana offers competitive benefits designed to support whole-person well-being, including:

• 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.
• Additional opportunities and programs to support personal wellness and smart healthcare decisions.