Grievances & Appeals Professional

Humana • Work at Home - Wisconsin, WI

1d • $59,300 - $80,900 • Remote

About The Position

Join Humana's Wisconsin Medicaid team as a Grievances and Appeals Professional and make a meaningful impact in the lives of our members. Reporting to the Manager of Consumer Engagement, you will advocate for member rights and ensure fair treatment by reviewing clinical documentation thoroughly and resolving concerns with skill and integrity. You will collaborate with dedicated clinical experts and teams across Humana to deliver thoughtful final determinations on grievances and appeals.

Requirements

• Bachelor's degree
• 3+ years of experience in social work, human services, healthcare, medical services, or a related field
• 2+ years of experience using Microsoft Word and Excel, including organizing, tracking, and manipulating data
• Demonstrated ability to work independently, manage multiple assignments or cases simultaneously, and meet established deadlines, turnaround times, or compliance requirements

Nice To Haves

• Experience with grievances and appeals processes, procedures, or case resolution
• Experience working with Medicaid or Medicare populations
• Experience processing medical claims or applying medical terminology
• Experience supporting individuals with intellectual/developmental disabilities, physical disabilities, or frail elder populations

Responsibilities

• Review, research, and help resolve formal grievances, appeals, informal complaints, and member concerns following applicable requirements and deadlines.
• Ensure concerns are handled fairly, thoroughly, and with appropriate documentation to support member rights.
• Investigate member and practitioner issues by gathering relevant information, reviewing case details, and identifying appropriate next steps.
• Collaborate with clinical reviewers, internal partners, and teams to evaluate documentation and support accurate final determinations.
• Help with conflict resolution and mediation efforts to address concerns in a respectful, and solution-focused manner.
• Document findings, actions, and outcomes to support case resolution and regulatory expectations.
• Help identify trends, process opportunities, or recurring issues that may influence the member experience.
• Maintain confidentiality and handle sensitive member information.

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level