Grievances & Appeals Representative II

Become a part of our caring community and help us put health first
 

This role will have a direct impact on Humana's Stars Ratings.  The Internal Review Team (IRT) is looking for someone who is excited about handling large volumes of inventory to distribute to associates across multiple teams.  

In this role, you will be reviewing all cases types to determine who can work them and then assigning the case to the next available associate to work.  

You will be responsible for communicating via email and MedHok to leadership and other associates who have been assigned different case types.  

This position is permanent Remote/Work at Home.  Work hours are Monday – Friday (8 – 4:30 with a Friday late shift until 6:30 pm).  There is also a rotating weekend shift, which could include Saturday and Sunday hours.

Use your skills to make an impact
 

Required Qualifications

• Must be able to work Monday – Thursday:  8a – 4:30p EST, Friday 10a - 6:30p EST with rotating weekends, but be flexible with your hours based on business needs to work possible overtime.
• Minimum 2 years of customer service and/or grievance & appeals experience
• Experience managing deadlines and competing priorities
• Strong data entry skills required
• Must have experience in a production driven environment
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Work-At-Home Requirements

• At minimum, a download speed of 25 mbps and an upload speed of 10 mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Undergraduate Degree
• Previous experience with MedHok, PaHub, and/or Service Read Only
• Previous experience in medical claims processing
• 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
• Experience with the Claims Administration System (CAS)
• Ability to manage large volume of inventory

Additional Information

• Must be able to work any 8-hour shift between the hours of 8:00 AM and 9:00 PM EST, Monday – Thursday, with a minimum schedule of 10:00 AM - 6:30 PM EST on Fridays.
• Potential weekend work is required on rotating basis from 8:00 AM to 4:30 PM, based on business needs.
• Overtime and holiday work may also be required; however, this is only mandatory based on business needs. Voluntary overtime may also be available.
• Grievances and Appeals (G&A) has an impact to our business, and, because of the complexities of our work, there is an 18-month commitment to this department. G&A will not allow transitions outside of area prior to the end of the 18-month commitment.
• As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.
• If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$40,000 - $52,300 per year

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.Application Deadline: 01-30-2025
About us
 Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.