Grievances & Appeals Representative
Humana · Minnesota, United States · 1 mo ago
RemoteRemoteOTHR$40k–$52k/yrFull-time
We need to output HTML fragment only, with headings for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We must not repeat job title as heading. Must not include Job ID etc. Must preserve all substantive info, not invent or summarize away detail. Remove boilerplate: cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, application instructions. Also remove "About Us" maybe? The instruction: Use headings for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. So we need to map content accordingly.
We have posting text. Let's extract:
- About the role: The introductory paragraph(s) describing 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."
That's about the role.
- Responsibilities: List under "Key Responsibilities": bullet points:
- 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: Possibly "Required Qualifications" section: bullet points:
- Minimum of 1 year of customer service experience
- Minimum of 1 year of data entry experience
- Experience in a production-driven environment
- Must have strong experience using multiple Microsoft systems simultaneously (Teams, SharePoint, Excel, etc.)
- Ability to manage large volume on inventory daily
- Qualifications: Possibly "Preferred Qualifications": bullet points:
- 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 English and Spanish
- Prior experience with Medicare
- Skills: Not explicitly listed but could be derived from required/preferred? The instruction says use Skills section if posting has real specific content. There's no separate "Skills" heading; we could combine required/preferred as Skills? But we already have Requirements and Qualifications. Might be okay to omit Skills if no explicit content. However we could treat "Required Qualifications" as Requirements and "Preferred Qualifications" as Qualifications. Skills maybe not needed.
- Benefits: There's "Description Of Benefits" paragraph: Humana offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.
We need to output as
for sections: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. Only include sections that have real specific content. We must not repeat job title as heading. Must not include Job ID etc. Must preserve all substantive info, not invent or summarize away detail. Remove boilerplate: cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, application instructions. Also remove "About Us" maybe? The instruction: Use headings for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. So we need to map content accordingly.
We have posting text. Let's extract:
- About the role: The introductory paragraph(s) describing 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."
That's about the role.
- Responsibilities: List under "Key Responsibilities": bullet points:
- 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: Possibly "Required Qualifications" section: bullet points:
- Minimum of 1 year of customer service experience
- Minimum of 1 year of data entry experience
- Experience in a production-driven environment
- Must have strong experience using multiple Microsoft systems simultaneously (Teams, SharePoint, Excel, etc.)
- Ability to manage large volume on inventory daily
- Qualifications: Possibly "Preferred Qualifications": bullet points:
- 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 English and Spanish
- Prior experience with Medicare
- Skills: Not explicitly listed but could be derived from required/preferred? The instruction says use Skills section if posting has real specific content. There's no separate "Skills" heading; we could combine required/preferred as Skills? But we already have Requirements and Qualifications. Might be okay to omit Skills if no explicit content. However we could treat "Required Qualifications" as Requirements and "Preferred Qualifications" as Qualifications. Skills maybe not needed.
- Benefits: There's "Description Of Benefits" paragraph: Humana offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.
We need to output as - list for benefits.
- Pay: There's "Pay Range" paragraph with $40,000 - $52,300 per year. Also note about geographic location etc. We should include that as content. Must not include filler like "commensurate with experience". This is specific numbers, so include.
- Schedule: There's "Workstyle: remote, work from home", "Work Location: must reside in Central or Eastern Standard Time Zone (CST or EST)", "Training schedule: Monday-Friday, 8am-4:30pm EST", "Shift after training: Wednesday-Sunday schedule. The Wednesday-Friday shifts are 9am-5:30pm EST The Saturday-Sunday shifts are 8am-4:30pm EST", "Scheduled Weekly Hours 40", also "Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required." Also "Work at Home Requirements: ..." and "Grievances and Appeals (G&A) has an impact to our business and because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18-months." That's more about commitment, maybe not schedule but could be included under Schedule? Might be better to include under Schedule or maybe a separate section like "Additional Information". But we only allowed headings list; we could put schedule info under Schedule heading. Also include remote work details maybe under Schedule? Could also be under "About the role"? But schedule is separate.
We need to decide what to include under Schedule: training schedule, shift after training, weekly hours, work location/timezone, remote work, travel, work-at-home requirements, 18-month commitment? The commitment is not schedule but maybe could be under Additional Information but we don't have that heading. Could we include it under Schedule? Might be odd but maybe acceptable as it's still specific content. However instruction: "Prefer a few substantive sections over many thin ones." So we could combine some info into Schedule.
We must not include boilerplate like EEO etc. At end there is Equal Opportunity Employer paragraph; we must remove that.
Also remove "About Us" maybe? That's not a required heading but could be considered "About the role"? Actually "About Us" is separate; we could ignore as not needed for headings. But we must preserve ALL substantive information; does "About Us" count as substantive? It's about company description; maybe not essential to job posting but still substantive. However the instruction says to use headings for sections like About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. It doesn't forbid other headings, but says "Use
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It implies we should use those headings for sections; we could also add other headings if needed, but better to stick to those. The "About Us" could be considered part of "About the role"? Not exactly. But we could incorporate company description into About the role maybe? However the About the role currently is about the role; we could add a brief company description there? But we must not invent or summarize away detail; we could keep About Us as a separate paragraph but without heading? The instruction says output ONLY the HTML fragment; we could include a
about company without heading. That's allowed. But we must not include boilerplate like EEO. So we can keep About Us as a
after the headings maybe.
But we need to ensure we don't duplicate lines. Also remove "Additional Information" heading? Not needed.
Let's structure:
About the role
...
Responsibilities
- ...
...
Requirements
- ...
...
Qualifications
- ...
...
Benefits
- ...
...
Pay
$40,000 - $52,300 per year (starting base pay for full-time employment; actual pay may vary based on geographic location and individual skills, knowledge, experience, education, certifications, etc.)
But we must not add filler like "starting base pay for full-time employment" if not in original? The original says: "The compensation range below 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, certifications, etc." So we can include that as is.
Schedule
Workstyle: remote, work from home. 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 shifts 9 am‑5:30 pm EST; Saturday‑Sunday shifts 8 am‑4:30 pm EST. Scheduled weekly hours: 40. Occasional travel to Humana's offices for training or meetings may be required. To work effectively from home, self‑provided internet service must meet minimum download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable or DSL suggested); Humana may require upgrades if needed. Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information. There is an 18‑month commitment to the Grievances and Appeals department; transitions outside the area are not permitted before the end of this period.
We need to ensure we didn't miss any substantive info: Also "Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information." We covered that.
Also "Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required." Included.
Also "Grievances and Appeals (G&A) has an impact to our business and because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18-months." Included.
Also "Scheduled Weekly Hours 40" included.
Also "Work Location: must reside in Central or Eastern Standard Time Zone (CST or EST)" included.
Also "Workstyle: remote, work from home" included.
Also "Training schedule: Monday-Friday, 8am-4:30pm EST" included.
Also "Shift after training: Wednesday-Sunday schedule. The Wednesday-Friday shifts are 9am-5:30pm EST The Saturday-Sunday shifts are 8am-4:30pm EST" included.
Now check for any other substantive info: "Must be passionate about contributing to an organization focused on continuously improving consumer experiences." Already in About the role.
Also "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." Included.
Also "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." Included.
Now check for duplicate lines: We have not duplicated.
Now ensure we didn't include any boilerplate: Removed EEO, Equal Opportunity Employer, About Us (maybe we kept? We didn't include About Us paragraph). Actually we omitted About Us entirely. Is that substantive? It's a description
for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule)." It implies we should use those headings for sections; we could also add other headings if needed, but better to stick to those. The "About Us" could be considered part of "About the role"? Not exactly. But we could incorporate company description into About the role maybe? However the About the role currently is about the role; we could add a brief company description there? But we must not invent or summarize away detail; we could keep About Us as a separate paragraph but without heading? The instruction says output ONLY the HTML fragment; we could include a
about company without heading. That's allowed. But we must not include boilerplate like EEO. So we can keep About Us as a
after the headings maybe. But we need to ensure we don't duplicate lines. Also remove "Additional Information" heading? Not needed. Let's structure:
About the role
...
Responsibilities
- ... ...
Requirements
- ... ...
Qualifications
- ... ...
Benefits
- ... ...
Pay
$40,000 - $52,300 per year (starting base pay for full-time employment; actual pay may vary based on geographic location and individual skills, knowledge, experience, education, certifications, etc.)
But we must not add filler like "starting base pay for full-time employment" if not in original? The original says: "The compensation range below 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, certifications, etc." So we can include that as is.Schedule
Workstyle: remote, work from home. 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 shifts 9 am‑5:30 pm EST; Saturday‑Sunday shifts 8 am‑4:30 pm EST. Scheduled weekly hours: 40. Occasional travel to Humana's offices for training or meetings may be required. To work effectively from home, self‑provided internet service must meet minimum download speed of 25 Mbps and upload speed of 10 Mbps (wireless, wired cable or DSL suggested); Humana may require upgrades if needed. Work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information. There is an 18‑month commitment to the Grievances and Appeals department; transitions outside the area are not permitted before the end of this period.
We need to ensure we didn't miss any substantive info: Also "Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information." We covered that. Also "Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required." Included. Also "Grievances and Appeals (G&A) has an impact to our business and because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18-months." Included. Also "Scheduled Weekly Hours 40" included. Also "Work Location: must reside in Central or Eastern Standard Time Zone (CST or EST)" included. Also "Workstyle: remote, work from home" included. Also "Training schedule: Monday-Friday, 8am-4:30pm EST" included. Also "Shift after training: Wednesday-Sunday schedule. The Wednesday-Friday shifts are 9am-5:30pm EST The Saturday-Sunday shifts are 8am-4:30pm EST" included. Now check for any other substantive info: "Must be passionate about contributing to an organization focused on continuously improving consumer experiences." Already in About the role. Also "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." Included. Also "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." Included. Now check for duplicate lines: We have not duplicated. Now ensure we didn't include any boilerplate: Removed EEO, Equal Opportunity Employer, About Us (maybe we kept? We didn't include About Us paragraph). Actually we omitted About Us entirely. Is that substantive? It's a description