Remote Medicaid Appeals Specialist

Humana Inc; Helena (MT); Remote; USD 43,000 - 56,000; Full time

Job summary

Humana Inc. seeks a Grievances & Appeals Representative 3 to process expedited Medicaid and AIP (dual) appeals, reviewing clinical documentation to determine if an appeal is warranted.

This is a high-volume, fast-paced role with multiple cases per hour and strict turnaround expectations. You will manage cases from assignment to resolution, perform analytic reviews, and communicate outcomes to members or providers, while adapting to process changes and maintaining effective collaboration with

Qualifications

• 1+ years of customer service experience.
• 1+ years of experience in the healthcare industry or medical field.
• Experience in production and meeting performance metrics.
• Intermediate experience with Microsoft Office programs and cross-system work.
• Experience handling a high-volume, changing workload and adapting to new processes.

Responsibilities

• Review and evaluate expedited Medicaid and AIP (dual) cases per hour.
• Manage cases from assignment to resolution with analytic review of clinical documentation.
• Assess case urgency and process within 24-hour turnaround times.
• Make outbound calls to deliver outcomes, request documentation or address issues.
• Stay current with mentor documents and workflows and monitor multiple workstreams.
• 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. seeks a Grievances & Appeals Representative 3 to process expedited Medicaid and AIP (dual) appeals, reviewing clinical documentation to determine if an appeal is warranted.

This is a high-volume, fast-paced role with multiple cases per hour and strict turnaround expectations. You will manage cases from assignment to resolution, perform analytic reviews, and communicate outcomes to members or providers, while adapting to process changes and maintaining effective collaboration with