Grievances & Appeals Professional

About the role

Join Humana's Wisconsin Medicaid team as a Grievances and Appeals Professional and make a meaningful impact in the lives of our members. Reporting to the Manager of Consumer Engagement, you will advocate for member rights and ensure fair treatment by reviewing clinical documentation thoroughly and resolving concerns with skill and integrity. You will collaborate with dedicated clinical experts and teams across Humana to deliver thoughtful final determinations on grievances and appeals.

Responsibilities

• Review, research, and help resolve formal grievances, appeals, informal complaints, and member concerns following applicable requirements and deadlines.
• Ensure concerns are handled fairly, thoroughly, and with appropriate documentation to support member rights.
• Investigate member and practitioner issues by gathering relevant information, reviewing case details, and identifying appropriate next steps.
• Collaborate with clinical reviewers, internal partners, and teams to evaluate documentation and support accurate final determinations.
• Help with conflict resolution and mediation efforts to address concerns in a respectful and solution-focused manner.
• Document findings, actions, and outcomes to support case resolution and regulatory expectations.
• Help identify trends, process opportunities, or recurring issues that may influence the member experience.
• Maintain confidentiality and handle sensitive member information.

Requirements

• Bachelor's degree
• 3+ years of experience in social work, human services, healthcare, medical services, or a related field
• 2+ years of experience using Microsoft Word and Excel, including organizing, tracking, and manipulating data
• Demonstrated ability to work independently, manage multiple assignments or cases simultaneously, and meet established deadlines, turnaround times, or compliance requirements

Preferred Qualifications

• Experience with grievances and appeals processes, procedures, or case resolution
• Experience working with Medicaid or Medicare populations
• Experience processing medical claims or applying medical terminology
• Experience supporting individuals with intellectual/developmental disabilities, physical disabilities, or frail elder populations

Workstyle

• Remote, work from home
• Potential for travel 1-2 times per year
• Typical workdays/hours: Monday – Friday, between 8:00 am – 5:00 pm CST

Work at Home Requirements

• Self-provided internet service must meet the following criteria: at minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps; wireless, wired cable or DSL connection is suggested.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
• While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Pay

The pay range 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, and certifications.

$59,300 - $80,900 per year

This job is eligible for a bonus incentive plan based upon company and/or individual performance.

Benefits

Humana offers competitive benefits that 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

About Us

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.

Learn more about what we offer at Humana.com and CenterWell.com.