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 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, and may apply intermediate mathematical skills. You will assist members, via phone or face-to-face, supporting quality-related goals. You will investigate and resolve member and practitioner issues. Decisions are typically focused 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, working under limited guidance due to previous experience, breadth and depth of knowledge of administrative processes, and organizational knowledge. Use your skills to make an impact!

Required Qualifications

• 1-3 years of customer service experience
• Less than 2 years of leadership experience
• Must have experience in the healthcare industry or medical field
• Strong data entry skills required
• Intermediate experience with Microsoft Word and Excel
• Must have experience in a production-driven environment
• Shifts may be scheduled Monday – Sunday 8 AM - 8 PM, but be flexible with your hours based on business needs to work possible overtime
• Previous experience in the healthcare or medical fields
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Associate's or Bachelor's Degree
• Previous inbound call center or related customer service experience
• 1-3 years of grievance and appeals experience
• Previous experience processing medical claims
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
• Prior experience with Medicare
• Experience with the Claims Administration System (CAS)
• 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

• 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.

$43,000 - $56,200 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance, and many other opportunities.

Application Deadline

09-04-2025

About Us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health.