Humana · 1 day ago
Director, Home Health Grievances & Appeals
United States
Full-time
Remote
Senior Level, Lead/Staff
$126K/yr - $174K/yr
10+ years expHumana is a healthcare company focused on providing personalized care. The Director, Home Health Grievances & Appeals will lead the audit and appeal processes, ensuring compliance and improving performance while managing data analytics and collaborating with leadership.
Health CareHealth InsuranceInsuranceVenture Capital
Responsibilities
Oversee the process for direction and support to clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects
Collaborates with leadership team in the development of an education plan to improve processes to preserve and recover revenue
Analyzes region-wide outcome indicators to measure achievement of quantitative and qualitative standards. Assists in the development, implementation and analysis of internal and external benchmarking programs to measure the region’s effectiveness in improving performance
Maintains region-wide Performance Improvement program which includes Customer Satisfaction, complaints, infection monitoring, Incident Reporting, and quarterly branch PI activity
Provides feedback and recommendations for changes to policies and processes, procedures and systems to enhance measures taken to improve performance
Communicate with Corporate leadership, Regional and Divisional leaders as appropriate to resolve issues that may place patients or the company at risk
Oversee educational in-services based on analysis of PI data and activities Acts as a resource for the Operations Support team and communicates Performance Improvement results
Participate in special projects and performs other duties as assigned
Qualification
Required
Bachelor's degree in Nursing or related field
10-15 years progressively responsible experience in home health or hospice industry that includes performance improvement and outcomes measurement
5 years' experience in a supervisory or teaching role
Thorough knowledge of health care policy, industry and related clinical practice
Knowledge in the interpretation and application of regulations and performance improvement standards
Strong Project management principles and clinical policy development/implementation required
Expert knowledge of all Medicare regulations and appeals processes
Excellent analytical skills with ability to interpret and apply regulatory requirements
Excellent verbal/written communication and presentation skills
Advanced knowledge with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC and CERT responses
Must be able to work well independently and in a team environment
Excellent communication and organization skills
Strong attention to detail
Healthcare industry experience preferred
Must read, write and speak fluent English
Must have good and regular attendance
Approximate percent of time required to travel: 30%
Performs other related duties as assigned
Preferred
Master's Degree preferred
Licenses/Certification: RN, PT or OT preferred
More than 3 years of grievance and appeals experience
Strong knowledge in Microsoft Access or experience with SQL Server databases
Previous experience processing medical claims
Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
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
H1B Sponsorship
Humana has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (282)
2024 (246)
2023 (284)
2022 (274)
2021 (212)
2020 (84)
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
2026-01-07
2026-01-06
2026-01-04
Company data provided by crunchbase