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About the Role

The Appeals Representative 4 is responsible for managing appeal denials by reviewing clinical documentation, determining further action, and validating final determinations in coordination with clinical and internal Humana partners. This role is crucial for ensuring accuracy, completeness, and compliance with CMS requirements within a production-driven environment.

Responsibilities

• Managed Level 1 appeal cases, ensuring accuracy, completeness, and compliance with CMS requirements.
• Reviewed clinical documentation to support appeal determinations and escalation decisions.
• Coordinated with clinical teams and internal partners to finalize appeal outcomes.
• Investigated and resolved member and provider issues with a focus on resolution.
• Maintained high productivity and quality standards in a production-driven environment.
• Ensured strict adherence to confidentiality and compliance regulations.
• Independently prioritized and managed multiple high-volume case assignments.
• Embrace change and support smooth transitions in work environment.

Requirements

• 1 or more years of Grievance & Appeals experience
• Strong data entry skills
• 1 or more years with Outlook (email and calendar management), Excel (data entry), Word (creating and editing documents) and Teams (meetings, chat, and file sharing)
• Self-provided internet service with at least a download speed of 25 Mbps and an upload speed of 10 Mbps (wireless, wired cable or DSL connection suggested).
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
• Occasional travel to Humana's offices for training or meetings may be required.

Skills

• Grievance & Appeals
• Data entry
• Outlook
• Excel
• Word
• Teams
• Medical claims processing
• Inbound call center/customer service
• CAS
• MedHOK
• Inventory management

Location

• Remote
• Eastern time zone

Work Type

• Remote
• Full-time

Experience Level

• 1 or more years of Grievance & Appeals experience
• 2 or more years of Grievance & Appeals experience

Education Level

• Associate Degree or higher

Salary/Compensations

• $48,300 - $65,900 per year

Benefits

• Medical benefits
• Dental benefits
• Vision benefits
• 401(k) retirement savings plan
• Time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• Short-term disability
• Long-term disability
• Life insurance

About the Company

• Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company.
• Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it.
• These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity

• It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.
• It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.
• This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.