Grievances & Appeals Representative

About the role

Become a part of our caring community 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. You will perform thorough reviews of clinical documentation to assess whether grievances, appeals, or additional requests are justified. Then, you will provide final determinations utilizing your expertise and collaboration with clinical and other Humana teams. Your contributions will directly support Humana's commitment to delivering high-quality service and making a positive difference in the lives of those we serve. 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
• Ability to manage large volume on inventory daily

Skills

• Strong experience using multiple Microsoft systems simultaneously (Teams, SharePoint, Excel, etc.)

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 competitive benefits that support whole‑person well‑being, including medical, dental and vision coverage, 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.

Pay

$40,000 – $52,300 per year (starting base pay for full‑time 40‑hour/week employment; actual pay may vary based on location, skills, experience, etc.)

Schedule

Remote work; must reside in Central or Eastern Standard Time Zone (CST or EST). Training schedule: 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. An 18‑month commitment to the Grievances & Appeals department is required, with no transfers outside the area before the commitment ends. Work‑from‑home requirements: minimum download speed 25 Mbps and upload speed 10 Mbps (wired cable, DSL or wireless suggested); dedicated workspace free of interruptions to protect member PHI/HIPAA information. Occasional travel to Humana offices for training or meetings may be required.