Grievances & Appeals Expedited Case Rep

The Grievances & Appeals Representative 3 works expedited Medicaid and AIP (dual) appeals cases and reviews clinical documentation to determine if an appeal is warranted. This is an extremely high-volume, fast-paced role, with the responsibility of moving several cases per hour. You will need to have proactive queue management, experience handling support requests across multiple work streams, ability to adjust to changing processes, and effective communication with managers and team leads.

You will report to the Grievances & Appeals Supervisor.

• Review and evaluate several expedited Medicaid and AIP (dual) cases per hour. Caseload volume varies as it is a consistently significant high-volume role.
• Manage cases from assignment to resolution, conducting analytic reviews of clinical documentation and collaborating with business partners to complete investigations.
• Assess case urgency and process cases in chronological order, ensuring resolution within strict turnaround times (typically 24 hours).
• Make outbound calls on every case to deliver outcome to members or providers, or request documentation, clarify case details or address outstanding issues.
• Stay current with frequently changing mentor documents and workflows.
• Monitor multiple work streams and adapt quickly to process changes.
• Communicate gaps or issues and seek guidance as needed.

• 1+ years of customer service experience
• 1+ years of experience in the healthcare industry or medical field
• Must have experience with production and meeting performance metrics
• Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems
• Experience managing a high-volume, rapidly changing workload while remaining self-sufficient, managing shifting priorities, and adapting to new processes without disruption

• Previous inbound call center or related customer service experience
• Prior Grievances and Appeals experience
• 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
• Knowledge of medical terminology

• Virtual training will start day one and will last for approximately four (4) weeks. Training will be held Monday through Friday and will follow a schedule between 8:00 am – 5:00 pm Eastern Time. Training hours will be communicated prior to the start date.
• Attendance is vital for success; no time off is allowed during training and is limited within the first 180 days.

• Following training, must be able to work 11:30 am – 8:00 pm Eastern, 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 Requirements:
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

Travel:
While this is a remote…