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. Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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.

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 on 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 English and Spanish
• Prior experience with Medicare

Benefits

• 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