Remote Appeals & Grievances Specialist

Humana; San Juan (PR); À distance; USD 48 000 - 66 000; Plein temps

Résumé du poste

Humana is seeking a Grievances and Appeals Representative 4 within the Internal Review Team to manage denials by reviewing clinical documentation and coordinating with clinical and internal Humana partners to validate final determinations.

You will handle Level 1 appeal cases, review documentation, and collaborate with teams to finalize outcomes, while maintaining high productivity and strict confidentiality in a remote work setup.

Qualifications

• 1 year of grievance & appeals and/or customer service experience.
• Strong data entry skills.
• Proficiency in Microsoft Office Applications.
• Experience in a production-driven environment.
• Experience prioritizing and delivering multiple assignments.
• Strong commitment to confidentiality and high-quality results.

Responsabilités

• Manage Level 1 appeal cases, ensuring accuracy and CMS compliance.
• Review clinical documentation to support appeal determinations and escalation decisions.
• Coordinate with clinical teams and internal partners to finalize outcomes.
• Investigate and resolve member and provider issues with timely resolution.
• Maintain high productivity and quality standards in a production-driven environment.
• Adhere to confidentiality and compliance regulations.
• Independently prioritize and manage multiple high-volume case assignments.
• Support smooth transitions in a dynamic work environment.

Connaissances

1 year grievance & appeals experience

Strong data entry

MS Office

Production-driven

Prioritizing multiple assignments

Confidentiality & quality

Formation

Associate’s or Bachelor’s degree

Description du poste

Humana is seeking a Grievances and Appeals Representative 4 within the Internal Review Team to manage denials by reviewing clinical documentation and coordinating with clinical and internal Humana partners to validate final determinations.

You will handle Level 1 appeal cases, review documentation, and collaborate with teams to finalize outcomes, while maintaining high productivity and strict confidentiality in a remote work setup.