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The Grievances & Appeals Representative 2 triages Medicaid and AIP (dual) expedited 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 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.

Use your skills to make an impact
 

Required Qualifications

• 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

Preferred Qualifications

• 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

Required Training Schedule:

• Virtual training will start day one and will run for approximately four (4) weeks with a schedule of 8:00 am – 4:30 pm Eastern Time, Monday through Friday.
• Attendance is vital for success; no time off is allowed during training and is limited within the first 120 days.

Required Work Schedule:

• Following training, must be able to work 9:00 am – 5:30 pm or 9:30 am – 6:00 pm Eastern Time, Tuesday through Saturday, with alternating holidays and overtime as needed.
• Hours are subject to change based on business needs.
• Must commit to working within the department for a minimum of eighteen (18) months.

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 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.

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.

 

$40,000 - $52,300 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 des