Director, Home Health Grievances & Appeals

Become a part of our caring community and help us put health first

The Director Denials Management provides leadership for the audit, appeal and review process to preserve and recover revenue while maintaining the highest level of clinical and regulatory integrity and compliance. Manages the Denials Management data analytics, denial and appeal process.

The Director, Home Health Grievances & Appeals assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy.

• Oversee the process for direction and support to clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects.
• Collaborates with leadership team in the development of an education plan to improve processes to preserve and recover revenue.
• Analyzes region-wide outcome indicators to measure achievement of quantitative and qualitative standards. Assists in the development, implementation and analysis of internal and external benchmarking programs to measure the region’s effectiveness in improving performance
• Maintains region-wide Performance Improvement program which includes Customer Satisfaction, complaints, infection monitoring, Incident Reporting, and quarterly branch PI activity
• Provides feedback and recommendations for changes to policies and processes, procedures and systems to enhance measures taken to improve performance
• Communicate with Corporate leadership, Regional and Divisional leaders as appropriate to resolve issues that may place patients or the company at risk
• Oversee educational in-services based on analysis of PI data and activities Acts as a resource for the Operations Support team and communicates Performance Improvement results
• Participate in special projects and performs other duties as assigned.

• Bachelor's degree in Nursing or related field
• 10-15 years progressively responsible experience in home health or hospice industry that includes performance improvement and outcomes measurement
• 5 years’ experience in a supervisory or teaching role
• Thorough knowledge of health care policy, industry and related clinical practice
• Knowledge in the interpretation and application of regulations and performance improvement standards
• Strong Project management principles and clinical policy development/implementation required
• Expert knowledge of all Medicare regulations and appeals processes
• Excellent analytical skills with ability to interpret and apply regulatory requirements
• Excellent verbal/written communication and presentation skills
• Advanced knowledge with Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC and CERT responses
• Must be able to work well independently and in a team environment
• Excellent communication and organization skills
• Strong attention to detail
• Healthcare industry experience preferred
• Must read, write and speak fluent English
• Must have good and regular attendance
• Approximate percent of time required to travel: 30%
• Performs other related duties as assigned

• Master’s Degree preferred
• Licenses/Certification: RN, PT or OT preferred
• More than 3 years of grievance and appeals experience
• Strong knowledge in Microsoft Access or experience with SQL Server databases
• Previous experience processing medical claims
• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from  with instructions on how to add the information into your official application on Humana’s secure website.

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