Grievances & Appeals Specialist - Remote

Humana, Inc.; Boise (ID); Remote; USD 40,000 - 52,000; Full time

Job summary

Humana is seeking a Grievances & Appeals Representative to manage grievances and appeals for members and providers. You will analyze clinical documentation, apply policies, and render final determinations in collaboration with clinical and Humana teams.

The role emphasizes accuracy, timely resolution, and compliance with regulatory expectations. The position supports a remote workforce with standard full-time hours, and travel to Humana offices is occasional.

Qualifications

• Must have customer service experience in a healthcare or hospital setting.
• Experience in a production-driven environment is required.
• Proficiency in Microsoft Word and Excel.
• Ability to work an 8-hour shift Mon–Fri 8am–8pm with possible overtime.
• Experience with grievance and appeal processes is preferred.
• Bilingual English/Spanish is a plus.

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 to assigned work.
• Prioritize workload to meet service expectations.
• Collaborate with internal teams to resolve complex issues.
• Escalate cases requiring additional review.

Skills

Customer service

Healthcare industry

Production environment

MS Word

MS Excel

Flexible schedule

Customer-centric mindset

Call center experience

Grievance and appeals experience

Medical terminology

Bilingual

Medicare knowledge

CAS system

Document management

Interpersonal skills

Education

Associate's or Bachelor's Degree

Tools

Claims Administration System (CAS)

Job description

Humana is seeking a Grievances & Appeals Representative to manage grievances and appeals for members and providers. You will analyze clinical documentation, apply policies, and render final determinations in collaboration with clinical and Humana teams.

The role emphasizes accuracy, timely resolution, and compliance with regulatory expectations. The position supports a remote workforce with standard full-time hours, and travel to Humana offices is occasional.