Humana · 3 hours ago
Grievances & Appeals Representative
United States
Full-time
Remote
Entry, Mid Level
$43K/yr - $56K/yr
1+ years expHumana Inc. is committed to putting health first for their customers and teammates. The Grievances & Appeals Representative 3 manages client denials and concerns by reviewing clinical documentation and delivering final determinations, while also performing advanced administrative and customer support duties.
Health CareHealth InsuranceInsuranceVenture Capital
Responsibilities
Manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties
Performs advanced administrative/operational/customer support duties that require independent initiative and judgment
Assists members, via phone or face to face, further/support quality related goals
Investigates and resolves member and practitioner issues
Decisions are typically focus on methods, tactics and processes for completing administrative tasks/projects
Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge
Qualification
Required
1 - 3 years of customer service experience
Less than 2 years of leadership experience
Must have experience in the healthcare industry or medical field
Strong data entry skills required
Intermediate experience with Microsoft Word and Excel
Must have experience in a production driven environment
Must be able to work Monday – Friday 8 - 5 but be flexible with your hours based on business needs to work possible overtime
Previous experience in the healthcare or medical fields
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred
Associate's or Bachelor's Degree
Previous inbound call center or related customer service experience
1 - 3 years of grievance and appeals experience
Previous experience processing medical claims
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) and MHK
Knowledge of medical terminology
Ability to manage large volume of documents including tracking, copying, faxing and scanning
Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population
Benefits
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
Company
Humana
Humana is a health insurance provider for individuals, families, and businesses.
10001+ employees
Funding
Current Stage
Public CompanyTotal Funding
$13.07B2025-05-30Post Ipo Debt· $5B
2025-03-03Post Ipo Debt· $1.25B
2024-03-11Post Ipo Debt· $2.25B
Leadership Team
Jim Rechtin
CEO and President
Colin Drylie
Senior Vice President, Experience Transformation
Recent News
Fierce Healthcare
2025-12-24
MarketScreener
2025-12-18
Fierce Healthcare
2025-12-18
Company data provided by crunchbase