Remote Grievances & Appeals Specialist

Humana, Inc.; Montpelier (VT); Remote; USD 40,000 - 52,000; Full time

Job summary

Humana, Inc. is seeking a Grievances & Appeals Representative to manage denials and concerns by performing analytic reviews of clinical documentation and delivering final determinations.

This remote role supports members and providers in the grievance and appeal process, applying Humana policies with attention to quality and service. Responsibilities include investigating concerns, documenting interactions, explaining outcomes, and collaborating with internal teams to resolve complex cases.

Qualifications

• Must have customer service experience.
• Experience in healthcare or medical field.
• Experience in a production-driven environment.
• Proficient with Microsoft Word and Excel.
• Able to work an 8-hour shift Mon-Fri 8am-8pm with overtime as needed.
• Passionate about improving consumer experiences.

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 and procedures to assigned work.
• Prioritize workload and manage tasks to meet service expectations.
• Collaborate with internal teams to resolve complex issues.
• Escalate concerns requiring additional review or action.

Skills

Customer service experience

Healthcare industry experience

Production-driven environment

Microsoft Word

Microsoft Excel

8-hour shift 8am-8pm (Mon-Fri) with OT

Focus on consumer experience

Education

Associate's or Bachelor's Degree

Tools

Microsoft Word

Excel

Job description

Humana, Inc. is seeking a Grievances & Appeals Representative to manage denials and concerns by performing analytic reviews of clinical documentation and delivering final determinations.

This remote role supports members and providers in the grievance and appeal process, applying Humana policies with attention to quality and service. Responsibilities include investigating concerns, documenting interactions, explaining outcomes, and collaborating with internal teams to resolve complex cases.