Grievances & Appeals Rep - IRT

Become a part of our caring community The Grievances and Appeals Representative 4 role in the Internal Review Team 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 partners. Key Responsibilities: • Manage Level 1 appeal cases, ensuring accuracy, completeness, and compliance with CMS requirements • Review clinical documentation to support appeal determinations and escalation decisions • Coordinate with clinical teams and internal partners to finalize appeal outcomes • Investigate and resolve member and provider issues with a focus on timely resolution • Maintain high productivity and quality standards in a production-driven environment • Ensure strict adherence to confidentiality and compliance regulations • Independently prioritize and manage multiple high-volume case assignments • Proactively embraces change and supports smooth transitions in a dynamic work environment Use your skills to make an impact Required Qualifications: • 1+ year of grievance & appeals and/or customer service experience • Strong data entry skills • Proficiency in Microsoft Office Applications • Experience in a production-driven environment • Experience prioritizing and delivering multiple assignments • Strong commitment to confidentiality and high-quality results Preferred Qualifications: • Associate's or Bachelor's degree • 2-4 years of grievance and appeals experience • Medical claims processing experience • Previous inbound call center experience • Experience with CAS and MedHOK • Inventory management experience Schedule and Attendance Requirements • Training: Monday-Friday, 8am-4:30pm EST your first 4-6 weeks. • Shift after training: Candidates must be flexible and able to work a variety of shifts, between the hours of 7am-7pm, including weekends. Availability to work on Saturdays and Sundays may be required based on business needs. Candidates must be able to accommodate schedule changes based on business needs. • Overtime and holiday work may be required based on business needs. • Time off requirement: To support a strong onboarding experience, time off is generally not scheduled during training or within the first 120 days of employment. Observed company holidays remain applicable. Exceptions may be considered based on business needs and prior approval. 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.$48,300 - $65,900 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. 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 or...