Grievances & Appeals Representative

**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 an a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills. The Grievances & Appeals Representative 3 assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions typically focus on methods, tactics and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works 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** **Training: Monday-Friday, 8am-4:30pm Eastern, for 5 weeks tentatively starting** **January 5th, 2026** **.** **Schedule: Monday-Friday 12:30pm-9:00pm or Tuesday-Saturday, 10:30am-7pm Eastern. Must be able to work possible overtime, weekends and holidays based on business needs.** **Required Qualifications** + **Minimum of two years of customer service experience** + **Prior experience working in the healthcare field and/or medical industry** + Excellent data entry capabilities + Proficiency with Microsoft Office, including intermediate skills in Outlook, Excel, and PowerPoint + Ability to adhere to process maps + Experience working in a fast-paced, production-oriented environment + Proven ability to prioritize tasks and manage inventory and workflow + Strong focus on customer service, with keen analytical and decision-making abilities + Robust technical skills, including the capability to set up and connect a computer with additional monitors, navigate multiple software systems and applications simultaneously, and effectively work from home + Availability of a distraction-free workspace at home **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 + Prior experience with Medicare + Experience with Clinical Guidance Exchange (CGX 2.0) + Knowledge of medical terminology + Ability to manage large volume of documents including tracking, copying, faxing and scanning + Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population **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 connection can be used only if approved by leadership. + Associates 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 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 an interviewing 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. + **Assessment:** If you are selected to move forward, you will receive an email to complete the Virtual Job Experience (VJE). This is an online activity where you will learn more about Customer Care jobs at Humana, try out some of the most common job tasks, and tell us more about yourself. Most people complete the VJE in approximately 30 minutes. To complete it, you will need a smart phone, computer or tablet with internet access, and speakers/headphones. We do not make job offers to candidates that do not complete the VJE. + **Video Prescreen** : If you are successful with your text screen, 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 will be invited to interview. If so, the recruiter will reach out to schedule. + **Offers** : Finalists from the interview will be contacted by a recruiter to discuss an offer for the job **Note** : Depending on the number of openings, the number of candidates who apply, and the schedules of interviewers and recruiters, this process may take several weeks or less; however, know that we are working hard to proceed as quickly as possible and to keep you informed. 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. **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 - 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, Medicaid, families, individuals, military service personnel, and communities at large. ​ **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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our