Grievances and Appeals Representative

Humana Inc; United States; Remote; USD 42,000 - 56,000; Full time

Job summary

Humana Inc. is seeking a Grievances & Appeals Representative 3 to manage member and provider inquiries, focusing on Part B denials and grievances. The role requires analytic review of clinical documentation and collaboration with clinical teams to determine warranted actions.

You will support members and providers by phone, resolve issues, and contribute to QA-driven processes while working remotely. Flexibility in scheduling is necessary.

Qualifications

• 1+ year of customer service experience in call center or retail settings.
• Experience in healthcare, pharmaceutical, or medical field.
• 1+ year of grievances & appeals experience.
• Experience in a production and QA driven environment.
• Strong data entry skills including Word and Excel.

Responsibilities

• Assist members and provider offices by phone.
• Investigate and resolve member and practitioner issues for Medicare Part B, Pharmacy, and related claims.
• Follow company production goals and QA metrics.

Skills

Customer service

Healthcare industry knowledge

G&A (Grievances & Appeals) experience

Data entry

Microsoft Office

Tools

Microsoft Word

Microsoft Excel

Job description

Become a part of our caring community The Grievances & Appeals Representative 3 manages members and provider PART B denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted. You will deliver final determination based on trained skillsets and partnerships with clinical and other Humana parties. You will perform advanced administrative and customer support tasks that require independent initiative and judgment.

The Grievances & Appeals Representative 3 responsibilities:

• Assist members and provider offices by phone
• Investigate and resolve member and practitioner issues for Medicare Part B Pharmacy, duel eligible Medicare/Medicaid, diabetic supply and related claims
• Follow company and department production goals and quality assurance (QA) metrics

Required Qualifications

• 1 or more years of customer service (i.e. call center or retail) experience
• Experience in the healthcare industry, pharmaceutical industry or medical field
• 1 or more years of grievance and appeals (G&A) experience
• Experience in a production and quality assurance driven environment
• Strong data entry skills including the Microsoft office suite (Word and Excel)
• Must be able to work any day Sunday - Saturday, 8-hour shifts between the hours of 7 a.m. - 7 p.m. EST, but be flexible with your hours based on business needs to work possible overtime
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Previous experience processing medical claims (Ideally Part B Medical Pharmacy claims)
• Experience with Medicare or dual eligible Medicare/Medicaid plans
• Knowledge of medical terminology
• Experience managing large volume of documents including tracking, copying, faxing and scanning
• Experience with PaHub (For processing medical appeals)
• Prior experience working in a remote/work at home environment
• Excellent interpersonal skills with the ability to sensitively and compassionately interact with geriatric population

Additional Information

Schedule: Sunday-Saturday 8-hour shifts between the hours of 7 a.m. - 7 p.m. Eastern Standard Time (EST) Full-Time 40 hours a week Must be flexible with your hours based on our needs to include potential Overtime

Work Style: Remote 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.

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.

Application Deadline: 11-06-2026

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.