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About the role
The Grievances and Appeals Representative 4 role in the Internal Review Team is responsible for managing appeal denials, by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partners.
What they're looking for
- 1+ year of grievance & appeals and/or customer service experience
- Strong data entry skills
- Proficiency in Microsoft Office Applications
- Experience in a production-driven environment
- Experience prioritizing and delivering multiple assignments
- Strong commitment to confidentiality and high-quality results
More about this role
The Grievances and Appeals Representative 4 role in the Internal Review Team is responsible for managing appeal denials, by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partners.
- Manage Level 1 appeal cases , ensuring accuracy, completeness, and compliance with CMS requirements
- Review clinical documentation to support appeal determinations and escalation decisions
- Coordinate with clinical teams and internal partners to finalize appeal outcomes
- Investigate and resolve member and provider issues with a focus on timely resolution
- Maintain high productivity and quality standards in a production-driven environment
- Ensure strict adherence to confidentiality and compliance regulations
- Independently prioritize and manage multiple high-volume case assignments
- Proactively embraces change and supports smooth transitions in a dynamic work environment
Use your skills to make an impact
- 1+ year of grievance & appeals and/or customer service experience
- Strong data entry skills
- Proficiency in Microsoft Office Applications
- Experience in a production-driven...
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