Grievances and Appeals Representative

Humana

3d•$43,000 - $56,200•Remote

About The Position

The Grievances & Appeals Representative 3 manages member and provider Part B denials and concerns by conducting comprehensive analytical reviews of 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 also performs advanced administrative and customer-support tasks requiring independent initiative and judgment. This is a remote work-at-home position with limited guidance. The representative assists members and provider offices by phone and investigates and resolves issues involving Medicare Part B Pharmacy, dual-eligible Medicare/Medicaid, diabetic supplies, and related claims. The role follows production goals and quality-assurance metrics and requires discretion in prioritizing requests and applying procedures. The schedule is 40 hours per week, with eight-hour shifts scheduled between 7 a.m. and 7 p.m. Eastern, Sunday through Saturday; flexibility and potential overtime are required based on business needs. Occasional travel to Humana offices for training or meetings may be required. Employees working from home must provide internet service with at least 25 Mbps download and 10 Mbps upload speeds and work from a dedicated space that protects member PHI/HIPAA information. The stated annual pay range is $43,000–$56,200. Humana lists medical, dental, and vision benefits; a 401(k) plan; paid time off and holidays; paid parental and caregiver leave; short- and long-term disability; and life insurance.

Requirements

At least 1 year of customer service experience, such as call center or retail experience.
Experience in the healthcare, pharmaceutical, or medical industry.
At least 1 year of grievance and appeals experience.
Experience working in a production- and quality-assurance-driven environment.
Strong data-entry skills, including proficiency with Microsoft Word and Excel.
Ability to work any day Sunday through Saturday, on eight-hour shifts between 7 a.m. and 7 p.m. EST, and flexibility to work possible overtime based on business needs.
Passion for contributing to an organization focused on continuously improving consumer experiences.

Nice To Haves

Previous experience processing medical claims, ideally Part B Medical Pharmacy claims.
Experience with Medicare or dual-eligible Medicare/Medicaid plans.
Knowledge of medical terminology.
Experience managing high volumes of documents, including tracking, copying, faxing, and scanning.
Experience with PaHub for processing medical appeals.
Prior experience working remotely or from home.
Excellent interpersonal skills and the ability to interact sensitively and compassionately with geriatric populations.

Responsibilities

Assist members and provider offices by phone.
Investigate and resolve member and practitioner issues involving Medicare Part B Pharmacy, dual-eligible Medicare/Medicaid, diabetic supplies, and related claims.
Conduct comprehensive analytical reviews of clinical documentation to determine whether a grievance, appeal, or further request is warranted.
Deliver final determinations using trained skills and partnerships with clinical and other Humana teams.
Follow company and department production goals and quality-assurance metrics.
Prioritize requests and interpret or adapt procedures, processes, and techniques using discretion and judgment.
Perform advanced administrative and customer-support tasks with independent initiative and judgment.