Grievances & Appeals Rep

Become a part of our caring community The Grievances & Appeals Representative 4 (Thursday-Monday shift) is responsible for managing appeal denials, by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partner. You will report to a Supervisor, Grievances & Appeals. As the Grievances & Appeals Representative 4 you will - Managed Level 1 appeal cases, ensuring accuracy, completeness, and compliance with CMS requirements. - Reviewed clinical documentation to support appeal determinations and escalation decisions. - Coordinated with clinical teams and internal partners to finalize appeal outcomes. - Investigated and resolved member and provider issues with a focus on resolution. - Maintained high productivity and quality standards in a production-driven environment. - Ensured strict adherence to confidentiality and compliance regulations - Independently prioritized and managed multiple high-volume case assignments. - Embrace change and support smooth transitions in work environment. Use your skills to make an impact Required Qualifications - 1 or more years of Grievance & Appeals experience - Strong data entry skills - 1 or more years experience with Outlook (email and calendar management), Excel (data entry), Word (creating and editing documents) and Teams (meetings, chat, and file sharing) Preferred Qualifications - Associate Degree or higher - 2 or more years of Grievance & Appeals experience - Medical claims processing experience - Previous inbound call center/customer service experience - Experience with CAS and MedHOK - Inventory management experience This is a remote role and will provide coverage for Eastern time zone hours. Training - Virtual Training will start day one of employment and runs the first 6-8 weeks with a schedule of 8:00 AM - 4:30 PM EST, Monday - Friday. Work Schedule Following Training - Must be able to work an 8-hour shift Thursday-Monday between 8:00 AM and 4:30 PM EST, with a minimum schedule of 10:00 AM EST – 6:30 PM EST on Friday's. - 5% shift differential for working Saturday and Sunday. - Overtime and holiday work may be required based on business needs HireVue As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. Work at Home To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: - At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. - Employees 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 employees 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. Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require as