Grievance & Appeals Representative

309 Humana Pharmacy Solutions, Inc.; United States; Remote; USD 40,000 - 52,000; Full time

Benefits offered by this job

Medical, dental and vision benefits

401(k) retirement plan

Paid time off and holidays

Disability insurance

Life insurance

Job summary

Humana, Inc. is seeking a Grievances & Appeals Representative 2 to manage denials and member/provider concerns through comprehensive review of clinical documentation and coordination with clinical teams.

The role involves semi-routine administrative and customer support tasks, resolving issues, and documenting interactions while applying established policies to deliver quality service. Remote work with travel to Humana offices as needed.

Qualifications

• Previous customer service experience.
• Previous experience in the healthcare industry or medical field.
• Must have experience in a production driven environment.
• Intermediate experience with Microsoft Word and Excel.
• Ability to work an 8-hour shift Monday - Friday between 8am-8pm with flexibility to work overtime.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Responsibilities

• Assist members and providers with grievance and appeal inquiries.
• Investigate and resolve member and practitioner concerns.
• Document interactions and maintain accurate records.
• Explain processes, policies, and resolution outcomes.
• Research issues and gather information to support case resolution.
• Apply departmental policies and procedures to assigned work.
• Prioritize workload and manage tasks to meet service expectations.
• Collaborate with internal teams to resolve complex issues.
• Escalate concerns requiring additional review or action.
• Support quality, compliance, and member experience goals.

Skills

Customer service

Healthcare industry experience

Production driven environment

Microsoft Word

Microsoft Excel

Education

Associate's or Bachelor's Degree

Tools

Microsoft Word

Microsoft Excel

Job description

Become a part of our caring community

The Grievances & Appeals Representative 2 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an 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 2 performs varied activities and moderately complex administrative/operational/customer support assignments. Performs computations. Typically works on semi-routine assignments. The Grievances & Appeals Representative supports members and providers by addressing concerns, resolving issues, and assisting with grievance and appeal processes. This role applies established policies and procedures while exercising judgment to prioritize work, interpret guidelines, and deliver quality service. As a Grievances & Appeals Representative you will: Assist members and providers with grievance and appeal inquiries. Investigate and resolve member and practitioner concerns. Document interactions and maintain accurate records. Explain processes, policies, and resolution outcomes. Research issues and gather information to support case resolution. Apply departmental policies and procedures to assigned work. Prioritize workload and manage tasks to meet service expectations. Collaborate with internal teams to resolve complex issues. Escalate concerns requiring additional review or action. Support quality, compliance, and member experience goals. Use your skills to make an impact

Required Qualifications

• Previous customer service experience
• Previous experience in the healthcare industry or medical field
• Must have experience in a production driven environment
• Intermediate experience with Microsoft Word and Excel
• Ability to work an 8-hour shift Monday - Friday between the hours of 8am-8pm with flexibility to work overtime based on business needs
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Associate's or Bachelor's Degree
• Previous experience in medical claims processing
• Previous inbound call center or related customer service experience 1 - 3 years of 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
• Experience with the Claims Administration System (CAS)
• 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 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.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

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.

$40,000 - $52,300 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

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.