Remote Grievances & Appeals Specialist (Medicaid)

Humana Inc; Honolulu (HI); On-site; USD 43,000 - 56,000; Full time

Job summary

Humana Inc. is seeking a Grievances & Appeals Representative 3 to expedite Medicaid and AIP (dual) appeals, review clinical documentation, and determine if an appeal is warranted in a high-volume, fast-paced environment.

You will manage cases from assignment to resolution, communicate outcomes to members or providers, and adapt to evolving mentor documents and workflows while reporting to the Grievances & Appeals Supervisor.

Qualifications

• 1+ years of customer service experience.
• 1+ years of experience in the healthcare industry or medical field.
• Experience with production and meeting performance metrics.
• Proficiency with Microsoft Office programs (Word, Excel, Outlook, Teams) and multi-system workflows.
• Experience handling a high-volume, changing workload independently.

Responsibilities

• Review and evaluate several expedited Medicaid and AIP (dual) cases per hour.
• Manage cases from assignment to resolution; analyze clinical documentation and collaborate to investigate.
• Assess case urgency and process in chronological order to meet 24-hour turnaround times.
• Make outbound calls to deliver outcomes, request documents, or address issues.
• Stay current with mentor documents and workflows.
• Monitor multiple workstreams and adapt to process changes.
• Communicate gaps or issues and seek guidance as needed.

Skills

Customer service

Healthcare experience

Performance metrics

MS Office

High-volume workload

Job description

Humana Inc. is seeking a Grievances & Appeals Representative 3 to expedite Medicaid and AIP (dual) appeals, review clinical documentation, and determine if an appeal is warranted in a high-volume, fast-paced environment.

You will manage cases from assignment to resolution, communicate outcomes to members or providers, and adapt to evolving mentor documents and workflows while reporting to the Grievances & Appeals Supervisor.