Grievances & Appeals Rep

Become a part of our caring community The Grievances & Appeals Representative 4 (Thursday-Monday shift) 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 partner. You will report to a Supervisor, Grievances & Appeals. As the Grievances & Appeals Representative 4 you will 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. Use your skills to make an impact Required Qualifications 1 or more years of Grievance & Appeals experience Strong data entry skills 1 or more years experience with Outlook (email and calendar management), Excel (data entry), Word (creating and editing documents) and Teams (meetings, chat, and file sharing) Preferred Qualifications Associate Degree or higher 2 or more years of Grievance & Appeals experience Medical claims processing experience Previous inbound call center/customer service experience Experience with CAS and MedHOK Inventory management experience This is a remote role and will provide coverage for Eastern time zone hours. Training Virtual Training will start day one of employment and runs the first 6-8 weeks with a schedule of 8:00 AM - 4:30 PM EST, Monday - Friday. Work Schedule Following Training Must be able to work an 8-hour shift Thursday-Monday between 8:00 AM and 4:30 PM E