Grievances & Appeals Representative 3

Employment Type: Full-time

Position Overview

Become a part of our caring community and help us put health first. The Grievances & Appeals Representative 3 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. You will then deliver final determinations based on trained skillsets and/or partnerships with clinical and other Humana parties.

This role performs advanced administrative/operational/customer support duties that require independent initiative and judgment. You may apply intermediate mathematical skills. The Grievances & Appeals Representative 3 assists members and providers via phone or written communication channels to investigate and resolve inquiries. Decisions typically focus on methods, tactics, and processes for completing administrative tasks/projects. You will regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes, and techniques while working under limited guidance due to previous experience and depth of knowledge.

Use your skills to make an impact!

Required Qualifications

• Minimum of 2 years of customer service experience.
• Must have experience in the healthcare industry or medical field.
• Must have experience in a metrics/production-driven environment.
• Strong data entry and attention to detail skills with the ability to manage multiple tasks in a fast-paced setting with competing priorities.
• Intermediate experience with Microsoft Word, Excel, Outlook, and Teams.

Training & Schedule

• Training: Monday-Friday, 8:00 AM - 4:30 PM Eastern, for 5 weeks tentatively starting August 25, 2025.
• Schedule: Tuesday-Saturday, 10:30 AM - 7:00 PM Eastern OR Wednesday-Saturday, 8:30 AM - 7:00 PM Eastern.
• Must be able to work possible overtime, weekends, and holidays based on business needs.

Preferred Qualifications

• Associate or Bachelor's Degree.
• Previous inbound call center or related customer service experience.
• Prior grievance 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.
• Experience with Clinical Guidance Exchange (CGX 2.0).
• Knowledge of medical terminology.
• Ability to manage a large volume of documents including tracking, copying, faxing, and scanning.
• Excellent interpersonal skills with the ability to sensitively and compassionately interact with the geriatric population.

Additional Information

Work at Home Guidance

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended.
• Wireless, wired cable, or DSL connection is suggested.
• Satellite, cellular, and microwave connections can be used only if approved by leadership.
• Associates who live and work from Home in the state of Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Interview Process

As part of our hiring process for this opportunity, we will be using technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

• Video Prescreen: If you are successful with the text prescreen, you will receive another communication to record a Video Prescreen. This is an online video activity using your phone, tablet, or computer; however, most candidates prefer using a computer or tablet.
• Interviews: Some candidates may be invited for further interviews.