[Remote] Grievances & Appeals Representative 2 - Medicaid

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.

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