Grievances & Appeals Representative

About the Role

Become a valued member of Humana's Internal Review Team as a Grievances & Appeals Representative 2. You will perform thorough reviews of clinical documentation to assess whether grievances, appeals, or additional requests are justified, and provide final determinations in collaboration with clinical and other Humana teams. Your contributions directly support Humana's commitment to high‑quality service and a positive impact on the lives of those we serve.

Responsibilities

• Assign cases to team members for submission to an independent entity for second‑level review.
• Monitor and record the number of cases assigned to the team and the distribution of cases among individual associates.
• Operate within established guidelines to maintain work expectations and quality standards, 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.

Required Qualifications

• Minimum of 1 year of customer service experience.
• Minimum of 1 year of data entry experience.
• Experience in a production‑driven environment.
• Strong experience using multiple Microsoft systems simultaneously (Teams, SharePoint, Excel, etc.).
• Ability to manage large volume 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 both languages.
• Prior experience with Medicare.

Workstyle & Schedule

• Remote, work‑from‑home position; must reside in Central or Eastern Standard Time Zone (CST or EST).
• Training schedule: Monday‑Friday, 8 am‑4:30 pm EST.
• Post‑training shifts:
  • Wednesday‑Friday: 9 am‑5:30 pm EST
  • Saturday‑Sunday: 8 am‑4 pm EST
• 18‑month commitment to the Grievances & Appeals department; transitions outside the area are not permitted before the end of the commitment.
• Home‑office requirements: dedicated space free of interruptions, internet download ≥ 25 Mbps and upload ≥ 10 Mbps (wireless, wired cable, or DSL). Humana may require an upgrade if needed.
• Occasional travel to Humana offices for training or meetings may be required.
• Scheduled weekly hours: 40.

Pay

Estimated starting base pay for full‑time (40 hours per week) employment: $40,000 – $52,300 per year. Actual compensation may vary based on geographic location, skills, experience, education, certifications, and other factors.

Benefits

• Medical, dental, and vision coverage.
• 401(k) retirement savings plan.
• Paid time off, company and personal holidays, paid parental and caregiver leave.
• Short‑term and long‑term disability insurance.
• Life insurance.
• Additional wellness and employee assistance programs supporting whole‑person well‑being.

About Humana

Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through Humana insurance services and CenterWell healthcare services, we help millions of people achieve their best health by delivering the care and service they need, when they need it. Our efforts improve quality of life for individuals with Medicare and Medicaid, families, military personnel, and communities at large. Learn more at Humana.com and CenterWell.com.