Grievances and Appeals Representative

CenterWell Senior Primary Care

. Manage member and provider denials and concerns .

Posted 9/15/2026part-timeRemote • United StatesJunior💰 $43,000 - $56,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing member and provider denials, conducting analytic reviews of clinical documentation, and resolving issues related to Medicare Part B Pharmacy and claims. Strong ability to deliver determinations through collaboration and maintain quality assurance in a production-driven environment.

Highest-signal resume keywords

Grievance And Appeals ExperienceCustomer Service ExperienceData Entry SkillsHealthcare Industry ExperienceQuality Assurance Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Analytic ReviewClaims InvestigationAdministrative SupportDecision MakingProcess Adaptation

Soft Skills

CollaborationProblem SolvingFlexibilityPassion For Improvement

Tools & Technologies

Microsoft Office SuiteWordExcel

Industry Keywords

Medicare Part BMedicaidPHIHIPAADual Eligible

About the role

Key responsibilities & impact

Manage member and provider denials and concerns
Conduct comprehensive analytic reviews of clinical documentation
Determine whether a grievance, appeal, or further request is warranted
Deliver final determinations through collaboration with clinical and other Humana parties
Perform advanced administrative and customer support tasks independently
Assist members and provider offices by phone
Investigate and resolve member and practitioner issues involving Medicare Part B Pharmacy, dual eligible Medicare/Medicaid, diabetic supply, and related claims
Follow company and department production goals and quality assurance metrics
Make decisions regarding methods and processes for administrative tasks and projects
Prioritize requests and interpret or adapt procedures, processes, and techniques

Requirements

What you’ll need

1 or more years of customer service experience, such as call center or retail experience
Experience in the healthcare, pharmaceutical, or medical field
1 or more years of grievance and appeals (G&A) experience
Experience in a production and quality assurance driven setting
Strong data entry skills, including the Microsoft Office suite (Word and Excel)
Ability to work 8-hour shifts on Friday, Saturday, and Sunday between 7 a.m. and 5 p.m. EST
Flexibility to adapt hours based on business needs
Passion for continuously improving consumer experiences
Minimum home internet speed of 25 Mbps download and 10 Mbps upload
Ability to work from a dedicated space without ongoing interruptions to protect member PHI / HIPAA information

Benefits

Comp & perks

Medical benefits
Dental benefits
Vision benefits
401(k) retirement savings plan
Paid time off
Company holidays
Personal holidays
Paid parental leave
Paid caregiver leave
Short-term disability
Long-term disability
Life insurance
Personal wellness support
Smart healthcare decision support
Occasional travel to Humana offices for training or meetings