Grievances & Appeals Lead

004 Humana Insurance Company; United States; Remoto; USD 86.000 - 119.000; Tempo pieno

Descrizione del lavoro

Humana, Inc. is seeking a Grievances & Appeals Lead to support the Medicare Grievance organization by coordinating IOP oversight, driving corrective actions, and aiding CMS audit readiness.

You will lead cross-functional teams, analyze data with Power BI, and advise executives on strategies to reduce risk while improving quality and compliance within grievance operations.

Competenze

• 7+ years in healthcare operations, compliance, process improvement, project management or related field.
• 1+ year of Medicare Grievances experience
• 2+ years of project leadership experience
• Advanced experience with reporting and Power BI
• Experience analyzing data, identifying trends and root causes, and supporting remediation efforts
• Lean or Six Sigma certification
• CMS program audit experience
• Knowledge of Microsoft Access or experience with SQL Server databases
• Experience using data and AI-driven insights to support process improvement and metric remediation
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

Mansioni

• Lead IOP identification, monitoring, trending, and reporting across grievance teams
• Coordinate corrective action plans and remediation efforts
• Partner with operational leaders to resolve identified risks promptly
• Support CMS audit readiness activities, including documentation, reporting, and governance routines
• Oversee compliance-related performance metrics and emerging operational risks
• Advise executives on functional strategies related to quality, compliance, and grievance operations

Conoscenze

Healthcare operations

Medicare Grievances

Project leadership

Power BI

Data analysis

Strumenti

SQL Server

Microsoft Access

Descrizione del lavoro

Become a part of our caring community

The Grievances & Appeals Lead supports the Medicare Grievance organization by coordinating Issue of Performance (IOP) oversight, driving corrective actions, supporting CMS audit readiness, and helping reduce compliance risk while advancing quality goals.

As the Grievances & Appeals Lead, you will:

• Lead IOP identification, monitoring, trending, and reporting across grievance teams


• Coordinate corrective action plans and remediation efforts


• Partner with operational leaders to resolve identified risks promptly


• Support CMS audit readiness activities, including documentation, reporting, and governance routines


• Oversee compliance-related performance metrics and emerging operational risks


• Advise executives on functional strategies related to quality, compliance, and grievance operations


• Use your skills to make an impact

Required Qualifications

• 7+ years in healthcare operations, compliance, process improvement, project management or related field


• 1+ year of Medicare Grievances experience


• 2+ years of project leadership experience


• Advanced experience with reporting and Power BI


• Experience analyzing data, identifying trends and root causes, and supporting remediation efforts

Preferred Qualifications

• Lean or Six Sigma certification


• CMS program audit experience


• Knowledge of Microsoft Access or experience with SQL Server databases


• Experience using data and AI-driven insights to support process improvement and metric remediation


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

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. $86,300 - $118,700 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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 atHumana.comand atCenterWell.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.