Humana · 1 day ago
Manager, Home Health Grievances & Appeals
United States
Full-time
Remote
Mid, Senior Level
$86K/yr - $119K/yr
5+ years expHumana is a leader in healthcare services, and they are seeking a Manager for Home Health Grievances & Appeals. This role involves managing client denials and concerns, conducting comprehensive reviews of clinical documentation, and guiding the audit and appeals process to ensure compliance and recover revenue.
Health CareHealth InsuranceInsuranceVenture Capital
Responsibilities
Provide direction and support to the clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects
Collaborates with clinical and operational leadership in the development of an education plan to improve processes to preserve and recover revenue
Directs orientation for new staff both within the department and at the branch level (as needed) to assure audit, appeals and any medical record review process flows are within company standards
Monitors, trends and analyzes data to assist in developing plans to improve clinical documentation to ensure regulatory compliance to safeguard or recoup earned revenue
Directs workflow process and assignments to ensure all audits, appeals and reviews are submitted timely for preservation of revenue and/or reimbursement
Directs audit activity leads the development of appeal strategies and review responses
Directs the review of medical records and the various levels of appeals in preparation for and participation in Administrative Law Judge hearings
Directs the regional managers to ensure audit, appeal and review processes are in place and effectively and efficiently implemented at the branch level
Directs the use of select EMR database information and the audit and denial management software
Directs the evaluation of agency readiness for all CMS audits and initiatives and guides the education at the agency level
Assist in promoting compliance with federal, state and local regulatory agencies
Protect the integrity of the organization, patients and co-workers by maintaining confidentiality of all patient and business information
Maintain and contribute to the efficiency of operations by consistently complying with all policies, procedures and guidelines of the company
Perform all job responsibilities with a friendly, positive and team-oriented attitude
Ensure compliance with all Company policies/procedures as related to Medicare billing practices and overall clinical operations
Participate in special projects and perform other duties as assigned
Qualification
Required
Thorough knowledge of health care policy, industry and related clinical practice
Project management principles and clinical policy development/implementation
Knowledge of all Medicare regulations and appeals processes
Analytical skills with ability to interpret and apply regulatory requirements
Excellent verbal/written communication and presentation skills
Knowledge of 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 organizational skills
Strong attention to detail
Must read, write and speak fluent English
Must have good and regular attendance
Approximate percentage of time required to travel: 20%
Performs other related duties as assigned
Bachelor or Associate degree in Nursing or Other Health Care related fields
Professional License in current state of residence
Minimum 5 years' experience in health care management
Preferred
10 years in Medical Certified home health care preferred
Healthcare industry experience preferred
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
Nwando Olayiwola
Chief Health Equity Officer & Senior Vice President
Recent News
2026-01-16
2026-01-16
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