Grievances & Appeals Rep
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The Grievances & Appeals Representative 4 (Thursday-Monday shift) is responsible for managing appeal denials, by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partner. You will report to a Supervisor, Grievances & Appeals.As the Grievances & Appeals Representative 4 you will
Managed Level 1 appeal cases, ensuring accuracy, completeness, and compliance with CMS requirements.
Reviewed clinical documentation to support appeal determinations and escalation decisions.
Coordinated with clinical teams and internal partners to finalize appeal outcomes.
Investigated and resolved member and provider issues with a focus on resolution.
Maintained high productivity and quality standards in a production-driven environment.
Ensured strict adherence to confidentiality and compliance regulations
Independently prioritized and managed multiple high-volume case assignments.
Embrace change and support smooth transitions in work environment.
Use your skills to make an impact
Required Qualifications
1 or more years of Grievance & Appeals experience
Strong data entry skills
1 or more years experience with Outlook (email and calendar management), Excel (data entry), Word (creating and editing documents) and Teams (meetings, chat, and file sharing)
Preferred Qualifications
Associate Degree or higher
2 or more years of Grievance & Appeals experience
Medical claims processing experience
Previous inbound call center/customer service experience
Experience with CAS and MedHOK
Inventory management experience
This is a remote role and will provide coverage for Eastern time zone hours.
Training
Virtual Training will start day one of employment and runs the first 6-8 weeks with a schedule of 8:00 AM - 4:30 PM EST, Monday - Friday.
Work Schedule Following Training
Must be able to work an 8-hour shift Thursday-Monday between 8:00 AM and 4:30 PM EST, with a minimum schedule of 10:00 AM EST – 6:30 PM EST on Friday's.
5% shift differential for working Saturday and Sunday.
Overtime and holiday work may be required based on business needs
HireVue
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Work at Home
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. Satellite, cellular and microwave connection can be used only if approved by leadership.
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40Pay Range
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.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “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.
About us
About Humana: 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.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
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