Grievances & Appeals Expedited Case Rep

Grievances & Appeals Expedited Case Rep

Location: Remote, Nationwide

Remote Job: Remote Job: Yes

widget: Full time

Category: Administrative and Support Services

Humana

Job ID: R-429272

Description

• Become a part of our caring community

• The Grievances & Appeals Representative 3 works expedited Medicaid and AIP (dual) appeals cases and reviews clinical documentation to determine if an appeal is warranted. This is an extremely high-volume, fast-paced role, with the responsibility of moving several cases per hour. You will need to have proactive queue management, experience handling support requests across multiple workstreams, ability to adjust to changing processes, and effective communication with managers and team leads. You will report to the Grievances & Appeals Supervisor.

As a Grievances & Appeals Representative 3, you will:

• Review and evaluate several expedited Medicaid and AIP (dual) cases per hour. Caseload volume varies as it is a consistently significant high-volume role.

• Manage cases from assignment to resolution, conducting analytic reviews of clinical documentation and collaborating with business partners to complete investigations.

• Assess case urgency and process cases in chronological order, ensuring resolution within strict turnaround times (typically 24 hours).

• Make outbound calls on every case to deliver outcome to members or providers, or request documentation, clarify case details or address outstanding issues.

• Stay current with frequently changing mentor documents and workflows.

• Monitor multiple workstreams and adapt quickly to process changes.

• Communicate gaps or issues and seek guidance as needed.

• Use your skills to make an impact

• Required Qualifications

• 1+ years of customer service experience

• 1+ years of experience in the healthcare industry or medical field

• Must have experience with production and meeting performance metrics

• Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems

• Experience managing a high-volume, rapidly changing workload while remaining self-sufficient, managing shifting priorities, and adapting to new processes without disruption

• Preferred Qualifications

• Previous inbound call center or related customer service experience

• Prior Grievances and Appeals experience

• Previous experience processing medical authorizations

• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

• Prior experience with Medicare or Medicaid

• Knowledge of medical terminology

Required Training Schedule:

• Virtual training will start day one and will last for approximately four (4) weeks. Training will be held Monday through Friday and will follow a schedule between 8:00 am – 5:00 pm Eastern Time. Training hours will be communicated prior to the start date.
• Attendance is vital for success; no time off is allowed during training and is limited within the first 180 days.

Required Work Schedule:

• Following training, must be able to work 11:30 am – 8:00 pm Eastern, Tuesday through Saturday, with alternating holidays and overtime as needed.

• Hours are subject to change based on business needs.

• Must commit to working within the department for a minimum of eighteen (18) months.

• 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 associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

• 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.

• 43000 - 56200 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

• Application Deadline: 10-01-2026

• About us

• About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

• 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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.

• We Love our jobs, you should too.

• Request an Accommodation

• If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this online application process and need an alternative method for applying, you may contact [email protected] for assistance.

• Employment Fraud Notice

• Humana will never ask a candidate for money for work equipment and network access or request access to personal accounts during the application process. Learn more about identifying and preventing employment fraud or report a suspected employment fraud case.

• Applicant Privacy Policy

• Review how we collect and use applicant information in our Applicant Privacy Policy.

• Labor Notices

• Review our federal, state, and local labor notices on our Legal Information page.

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• At Humana, caring is everything

• And when you work here, you feel it. It’s how you grow. It’s how you’re welcomed into the associate community. It’s what guides us in helping people acheive their best health. And it forms the connection each of us have for the people we serve.

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