Grievance & Appeals Representative

Humana

2d•$40,000 - $52,300•Remote

About The Position

The Grievances & Appeals Representative 2 manages client denials and concerns by comprehensively reviewing clinical documentation to determine whether a grievance, appeal, or further request is warranted. The representative delivers final determinations using trained skills and partnerships with clinical and other Humana teams. The role includes varied, moderately complex administrative, operational, and customer-support assignments, computations, and semi-routine work. The representative supports members and providers by addressing concerns, resolving issues, and assisting with grievance and appeal processes. The role applies established policies and procedures while using judgment to prioritize work, interpret guidelines, and provide quality service.

Requirements

Previous customer service experience.
Previous experience in the healthcare industry or medical field.
Experience in a production-driven environment.
Intermediate experience with Microsoft Word and Excel.
Ability to work an 8-hour shift Monday through Friday between 8 a.m. and 8 p.m., with flexibility to work overtime based on business needs.
Passion for contributing to an organization focused on continuously improving consumer experiences.

Nice To Haves

Associate's or bachelor's degree.
Previous experience in medical claims processing.
Previous inbound call center or related customer service experience.
One to three years of grievance and appeals experience.
Medical terminology experience or knowledge.
Bilingual in English and Spanish, with the ability to read, write, and speak both languages.
Prior experience with Medicare.
Experience with the Claims Administration System (CAS).
Ability to manage large volumes of documents, including tracking, copying, faxing, and scanning.
Excellent interpersonal skills and the ability to interact sensitively and compassionately with the geriatric population.

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.
Support quality, compliance, and member experience goals.
Review clinical documentation to determine whether a grievance, appeal, or further request is warranted and deliver final determinations.