Grievances & Appeals Representative

Become a valued member of Humana’s Internal Review Team as a Grievances & Appeals Representative, where you will play a critical role in addressing client concerns and denials. In this position, you will perform thorough reviews of clinical documentation to assess whether grievances, appeals, or additional requests are justified, and provide final determinations utilizing your expertise and collaboration with clinical and other Humana teams. Your contributions will directly support Humana’s commitment to delivering high-quality service and making a positive difference in the lives of those we serve. Assigns cases to team members for submission to an independent entity for 2nd level review. Monitors and records the number of cases assigned to the team, as well as the distribution of cases among individual associates. Operates within established guidelines to maintain work expectations and quality standards, while exercising discretion in prioritizing tasks and managing timelines with minimal supervision. Demonstrates flexibility and resilience in adapting to evolving processes and a fast-paced work environment.