Grievances & Appeals Rep - Medicaid Intake

Description du poste:

Become a part of our caring community

You will report to the Grievances & Appeals Supervisor and be part of the Resolution Team. The Grievances & Appeals Representative 2 triages Medicaid and AIP (dual) cases and reviews clinical documentation to determine if a grievance or appeal is warranted. This is an extremely high-volume, fast-paced role, with the responsibility of moving several cases per hour. We ask that you have proactive queue management, attention to changing processes, experience handling support requests across multiple workstreams, and effective communication with managers and team leads.

As a Grievances & Appeals Representative 2, you will:
* Review and evaluate several cases per hour by identifying valid Medicaid and AIP (dual) grievances and appeals cases.
* Assess case priorities while processing in chronological order, ensuring you handle all cases within strict turnaround times ranging from 24 hours to 5 days.
* Conduct analytic reviews of clinical documentation to determine case validity, including investigative work to find the denial.
* Make outbound calls to members or providers to request documentation, clarify case details or address outstanding issues.
* Review and code cases, routing them to the appropriate queue while collaborating with leadership to maintain accuracy.
* 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

ALL CANDIDATES: PLEASE INCLUDE A CURRENT RESUME FOR CONSIDERATION.

Required Qualifications:

* Must reside in the central or eastern time zone
* 2+ years of customer service experience
* Proficient in Microsoft Word and Excel, as candidate will need to use Word letter templates and Excel for case tracking
* Experience in production environments and consistently meeting performance metrics
* Experience managing a high-volume workload across multiple software systems, ensuring thoroughly documented outcomes and minimal data entry error rates

Preferred Qualifications:

* Associate or bachelor's degree
* Prior Grievances and Appeals experience
* Experience in medical claims processing
* Previous inbound call center or related customer service experience
* Knowledge of medical terminology
* Prior experience with Medicaid or Medicare
* Experience with CAS, CRM, CGX, Pahub, RxNova, or Service Read Only

Additional Information

Required Training Schedule: 8:00 am - 4:30 pm Eastern, Monday through Friday, for two to four weeks.
Required Work Schedule: 11:00 am - 7:30 pm in your time zone (Central/Eastern), Tuesday through Saturday, with overtime as needed.
* Must commit to working within the department for a minimum of eighteen (18) months.
* Hours are subject to change based on business need.

Work-at-Home Information:

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.
* Satellite, cellular and microwave connection can be used only if approved by leadership.
* Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
* Humana will provide Home or Hybrid Home/Office employees 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.

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 RangeThe 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.

$40,000 - $52,300 per year

Description of BenefitsHumana, 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: 05-25-2026

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.

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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