Grievances & Appeals Representative

About the role

Join 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 work supports Humana’s commitment to high‑quality service and positively impacts 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 a large daily inventory volume.

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 and Schedule

Remote, work‑from‑home position. Candidates must reside in the Central or Eastern Standard Time Zone (CST or EST).

Training schedule: Monday – Friday, 8 am – 4:30 pm EST.

Shift after training (Wednesday – Sunday):

• Wednesday – Friday: 9 am – 5:30 pm EST
• Saturday – Sunday: 8 am – 4:pm EST

There is an 18‑month commitment to the Grievances & Appeals department; transitions outside the area are not permitted before the end of this period.

Work‑from‑home requirements: minimum internet speed of 25 Mbps download and 10 Mbps upload (wireless, wired cable, or DSL). Employees must work from a dedicated space free of interruptions to protect PHI/HIPAA information. Humana may require an upgrade to the internet service 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 ranges from $40,000 to $52,300 per year, depending on geographic location, skills, experience, education, and certifications.

Benefits

Humana offers competitive, whole‑person benefits, including medical, dental, and vision coverage; a 401(k) retirement savings plan; paid time off (including holidays, parental and caregiver leave); short‑term and long‑term disability; life insurance; and additional wellness and healthcare resources.

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 Medicare and Medicaid beneficiaries, families, individuals, military personnel, and communities nationwide.