Remote Medicaid Grievances & Appeals Specialist

Humana Inc; Augusta (ME); Remote; USD 43,000 - 56,000; Full time

Benefits offered by this job

Medical, dental & vision

401(k) retirement savings plan

Paid time off & holidays

Parental and caregiver leave

Disability & life insurance

Job summary

Humana Inc. in the United States is seeking a Grievances & Appeals Representative 3 to handle expedited Medicaid and dual AIP appeals, review clinical documentation, and determine whether an appeal is warranted.

This is a high-volume, fast-paced role with quotas and strict turnaround times. You will manage cases from assignment to resolution, perform analytic reviews with partners, and communicate outcomes by phone to members or providers.

Qualifications

• 1+ year of customer service experience.
• 1+ year in the healthcare industry or medical field.
• Experience producing and meeting performance metrics.
• Intermediate proficiency with Word, Excel, Outlook and Teams; comfortable with multiple systems.
• Ability to handle a high-volume, changing workload with minimal supervision.

Responsibilities

• Review expedited Medicaid and dual AIP cases and determine if an appeal is warranted.
• Manage cases from assignment to resolution with analysis of clinical documentation.
• Assess case urgency and process within strict 24-hour turnaround times.
• Make outbound calls to deliver outcomes or request documentation.
• Stay current with mentor documents and evolving workflows.
• Communicate gaps or issues and seek guidance as needed.

Skills

Customer service

Healthcare experience

Performance metrics

MS Office

High-volume workload

Bilingual English/Spanish

Tools

MS Office Suite

Job description

Humana Inc. in the United States is seeking a Grievances & Appeals Representative 3 to handle expedited Medicaid and dual AIP appeals, review clinical documentation, and determine whether an appeal is warranted.

This is a high-volume, fast-paced role with quotas and strict turnaround times. You will manage cases from assignment to resolution, perform analytic reviews with partners, and communicate outcomes by phone to members or providers.