Grievances & Appeals Representative

Humana • New York, VT

3d • $40,000 - $52,300 • Remote

About The Position

Become a valued member of Humana's Internal Review Team as a Grievances & Appeals Representative 2, where you will play a critical role in addressing client concerns and denials. You will perform thorough reviews of clinical documentation to assess whether grievances, appeals, or additional requests are justified. Then, you will provide final determinations utilizing your expertise and collaboration with clinical and other Humana teams. Your contributions will directly support Humana's commitment to delivering high-quality service and making a positive difference in the lives of those we serve. Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Requirements

• Minimum of 1 year of customer service experience
• Minimum of 1 year of data entry experience
• Experience in a production-driven environment
• Must have strong experience using multiple Microsoft systems simultaneously (Teams, SharePoint, Excel, etc.)
• Ability to manage large volume on inventory daily

Nice To Haves

• Previous inbound call center or related customer service experience
• Previous grievance and appeals experience
• Medical terminology experience
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• Prior experience with Medicare

Responsibilities

• Assign cases to team members for submission to an independent entity for 2nd level review.
• Monitor and record the number of cases assigned to the team, as well as the distribution of cases among individual associates.
• Operate within established guidelines to maintain work expectations and quality standards, while exercising discretion in prioritizing tasks and managing timelines with minimal supervision.
• Demonstrate flexibility and resilience in adapting to evolving processes and a fast-paced work environment.

Benefits

• medical
• dental
• 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
• Education Level: No Education Listed