Note: The job is a remote job and is open to candidates in USA. Humana is a leading U.S. healthcare company focused on delivering care and services to millions. They are seeking a Grievances & Appeals Representative 2 to manage expedited Medicaid and AIP cases, requiring effective communication and analytical skills to determine case validity and meet strict turnaround expectations.
Responsibilities
- Review and evaluate several cases per hour by identifying valid expedited Medicaid and AIP (dual) cases. Caseload volume varies as it is a consistently significant high-volume role
- Recognize urgent vs. routine cases and meet strict turnaround expectations (15–30 minutes)
- 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 verbally acknowledge receipt of valid cases
- Work closely with leadership, who will assign cases to appropriate team contacts once your investigations are complete and validity is determined
- 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
Skills
- 1+ years of customer service experience
- Must have experience with production and meeting metrics
- Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems
- Associate or bachelor's Degree
- Previous inbound call center or related customer service experience
- Prior experience with grievance and appeals
- Previous experience processing medical authorizations
- Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
- Prior experience with Medicare or Medicaid
- Experience with MHK, CGX, Guiding Care, and PA Hub
- Knowledge of medical terminology
Benefits
- 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
Company Overview
Humana is a health insurance provider for individuals, families, and businesses. It was founded in 1964, and is headquartered in Louisville, Kentucky, USA, with a workforce of 10001+ employees. Its website is http://www.humana.com.