Grievances & Appeals Representative
About the role
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 by reviewing clinical documentation to assess the justification of grievances, appeals, or additional requests and providing final determinations in collaboration with clinical and other Humana teams. This remote position requires residence in the Central or Eastern Standard Time Zone, includes an 18‑month commitment to the Grievances & Appeals department, and requires a dedicated workspace with internet service of at least 25 Mbps download and 10 Mbps upload to protect member PHI/HIPAA information. Occasional travel to Humana offices for training or meetings may be required. You must be passionate about contributing to an organization focused on continuously improving consumer experiences.
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.
Requirements
- 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 on inventory daily.
Qualifications
- Previous inbound call center or related customer service experience.
- Previous grievance and appeals experience.
- Medical terminology experience.
- Bilingual (English and Spanish); ability to read, write, and speak both languages.
- Prior experience with Medicare.
Benefits
Humana offers medical, dental and vision benefits, a 401(k) retirement savings plan, paid time off (including company and personal holidays, paid parental and caregiver leave), short‑term and long‑term disability, life insurance, and many other opportunities supporting whole‑person well‑being.
Pay
$40,000 - $52,300 per year
Schedule
Training: Monday‑Friday, 8 am‑4:30 pm EST. After training: Wednesday‑Sunday schedule – Wednesday‑Friday 9 am‑5:30 pm EST, Saturday‑Sunday 8 am‑4:30 pm EST. Scheduled weekly hours: 40.