Grievances & Appeals Rep

About the role

This is a remote role providing coverage for Eastern time zone hours. You will report to a Supervisor, Grievances & Appeals, and manage Level 1 appeal cases, ensuring accuracy, completeness, and compliance with CMS requirements.

Responsibilities

• 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

Training: Virtual training starts day one of employment and runs the first 6-8 weeks with a schedule of 8:00 AM - 4:30 PM EST, Monday - Friday.

Work Schedule Following Training: Must be able to work an 8-hour shift Thursday-Monday between 8:00 AM and 4:30 PM EST, with a minimum schedule of 10:00 AM EST – 6:30 PM EST on Fridays.

5% shift differential for working Saturday and Sunday. 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 their internet expense.
• Humana will provide telephone equipment appropriate to meet business requirements.
• 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 is $48,300 - $65,900 per year for full-time (40 hours per week) employment. 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

• 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.
• Other opportunities designed to support whole-person well-being.