Grievances & Appeals Expedited Case Rep

Humana; United States; Remote; USD 43,000 - 56,000; Full time

Job summary

Humana is seeking a Grievances & Appeals Representative 3 to efficiently process expedited Medicaid and AIP (dual) appeals while reviewing clinical documentation. This is a high-volume, fast-paced role with a focus on timely resolutions.

This remote position requires proactive queue management, strong communication with managers and team leads, and the ability to adapt to changing processes. Training and travel considerations are part of the role.

Qualifications

• 1+ years of customer service experience.
• 1+ years in healthcare/medical field.
• Experience with production and meeting performance metrics.
• Proficient in Word, Excel, Outlook, Teams; comfortable with multiple software systems.
• Capable of handling a high-volume, rapidly changing workload while staying self-sufficient.

Responsibilities

• Review and evaluate expedited Medicaid and AIP (dual) cases per hour.
• Manage cases from assignment to resolution and review clinical documentation.
• Assess urgency and process within strict turnaround times (typically 24 hours).
• Make outbound calls to deliver outcomes or request documentation and clarify details.
• Monitor multiple workstreams and adapt quickly to process changes; communicate gaps as needed.

Skills

Customer service

Healthcare experience

Performance metrics

Microsoft Office

High-volume workload

Tools

Microsoft Office Suite

Job description

Remote, Nationwide

The Grievances & Appeals Representative 3 works expedited Medicaid and AIP (dual) appeals cases and reviews clinical documentation to determine if an appeal is warranted. This is an extremely high-volume, fast-paced role, with the responsibility of moving several cases per hour. You will need to have proactive queue management, experience handling support requests across multiple workstreams, ability to adjust to changing processes, and effective communication with managers and team leads. You will report to the Grievances & Appeals Supervisor.

As a Grievances & Appeals Representative 3, you will:

Review and evaluate several expedited Medicaid and AIP (dual) cases per hour. Caseload volume varies as it is a consistently significant high-volume role.

Manage cases from assignment to resolution, conducting analytic reviews of clinical documentation and collaborating with business partners to complete investigations.

Assess case urgency and process cases in chronological order, ensuring resolution within strict turnaround times (typically 24 hours).

Make outbound calls on every case to deliver outcome to members or providers, or request documentation, clarify case details or address outstanding issues.

Stay current with frequently changing mentor documents and workflows.

Monitor multiple workstreams and adapt quickly to process changes.

Communicate gaps or issues and seek guidance as needed.

Use your skills to make an impact

Required Qualifications

• 1+ years of customer service experience
• 1+ years of experience in the healthcare industry or medical field
• Must have experience with production and meeting performance metrics
• Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems
• Experience managing a high-volume, rapidly changing workload while remaining self-sufficient, managing shifting priorities, and adapting to new processes without disruption

Preferred Qualifications

• Previous inbound call center or related customer service experience
• Prior Grievances and Appeals experience
• Previous experience processing medical authorizations
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• Prior experience with Medicare or Medicaid
• Knowledge of medical terminology

Required Training Schedule:

Virtual training will start day one and will last for approximately four (4) weeks. Training will be held Monday through Friday and will follow a schedule between 8:00 am - 5:00 pm Eastern Time. Training hours will be communicated prior to the start date.

Attendance is vital for success; no time off is allowed during training and is limited within the first 180 days.

Required Work Schedule:

Following training, must be able to work 11:30 am - 8:00 pm Eastern, Tuesday through Saturday, with alternating holidays and overtime as needed.

Hours are subject to change based on business needs.

Must commit to working within the department for a minimum of eighteen (18) months.

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.

$43,000 - $56,200 per year