Grievance & Appeals 2 at Humana

The Grievances & Appeals Representative 2 will manage client denials and concerns by conducting comprehensive analytic reviews of clinical documentation to determine if a grievance, appeal, or further request is warranted. They will deliver final determinations based on trained skillsets and/or partnerships with clinical and other Humana parties. This role involves performing varied administrative, operational, and customer support assignments, including computations. The representative will investigate and resolve member and practitioner issues, assist members via phone or face-to-face, and support quality-related goals. Decisions will focus on interpreting area/department policy and methods for completing assignments, working within defined parameters with some latitude over prioritization and timing, and operating under minimal direction.