Grievances & Appeals Representative

Become a part of our caring community and help us put health first

The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and / or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative / operational / customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.

What we need your help with :

• Managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted.
• Perform advanced administrative and / or customer support duties that require independent initiative and judgment.
• From time to time apply intermediate mathematical skills and regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques.
• Work under limited guidance at the comfort of your home due to previous experience / breadth and depth of knowledge of administrative processes and organizational knowledge.

Use your skills to make an impact

Required Qualifications

1 or more years of customer service experience

Strong data entry skills required

Proficiency with Microsoft Office applications

Must have experience in a production driven environment

Experience with the ability to prioritize and manage inventory and workflow

Customer focused, analytical and decision-making skills

Strong technical skills with the ability to work across multiple software systems / computer applications simultaneously and comfortably work remotely out of your home

Required Schedule :

Training : Virtual training will begin on day one of employment and runs for 5 weeks with a schedule of 8 : 00 am – 4 : 30 pm EST, Monday – Friday.

Please note that training is a critical stage of associate development. Attendance is vital for success, so no time off is allowed during training or within 120-day appraisal period

New Hire Training requires you to be appropriately dressed, on time and on camera via the facilitated Zoom classroom instruction for attendance.

Work Schedule : Your shift after training will be 10 : 30 am – 7 : 00 pm EST, Tuesday - Saturday.

Mandatory Overtime and business need for inventory, may include weekend days and rotation of holidays [including New Years, MLK Day, Memorial Day, Juneteenth, 4th of July, Labor Day, Thanksgiving and the day after, and / or Christmas].  Hours are subject to change based on business needs   but are always communicated ahead of the need . )

This position requires learning many systems, policies, and tools, and it takes time to become proficient in the role. You must be willing to remain in this position for a period of eighteen (18) months before applying to other Humana opportunities.

Preferred Qualifications

Associate or Bachelor’s degree

Previous experience in the healthcare or medical field

Humana’s operating systems : MHK (MedHok), CCP / GCP / CAS, CI, CGX

Previous inbound call center or related customer service experience

Grievance and appeals experience

Prior experience interpreting Member Benefits and Medical Claims

Previous experience processing medical authorizations

Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

Prior experience with Medicare

Experience with the Clinical Guidance Exchange, CGX 2.0

Knowledge of medical terminology

Ability to manage large volume of documents including tracking, copying, faxing and scanning

Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population

Additional Information

Work at Home Guidance

To ensure Home or Hybrid Home / Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home / Office associates must meet the following criteria :

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended.

Associates in this role are required to be hard-wired to their internet connection. Wireless, satellite, cellular and microwave connections are not permitted.

Associates 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 associates 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.

Interview Process

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.

Text Prescreen : Shortly after submitting your application, you may receive both a text message and email requesting you to complete 10 to 15 prescreen questions with either yes or no answers. The text message may arrive prior to the email. If you prefer to answer via computer or tablet, wait for the email.

Assessment : If the text prescreen is passed, you will receive another communication to take the Grievances and Appeals Assessment. This is an online activity where you will see a Realistic Job Preview to learn more about the job and then be asked to answer questions where 30 minutes should be set aside to complete. You can complete the assessment on your phone, tablet or computer; however, most candidates prefer using a computer or tablet.

Video Prescreen : If you are successful with the assessment, you will receive another communication to record a Video Prescreen. This is an online video activity using your phone, tablet, or computer; however, most candidates prefer using a computer or tablet.

Interviews : Some candidates will be invited to interview with a leader. If so, the recruiter will reach out to schedule.

Offers : Finalists from the interview will be contacted by a recruiter to discuss an offer for the job

Note : Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed.

Scheduled Weekly Hours

Pay 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.

43,000 - $56,200 per year

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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE : HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our

Salary : $43,000 - $56,200