Grievances and Appeals Representative

Humana

. Manage member and provider Part B denials and concerns .

Posted 10/28/2026full-timeRemote • United StatesJunior💰 $43,000 - $56,200 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in managing member and provider Part B denials, conducting analytic reviews of clinical documentation, and processing medical claims. Strong ability to deliver determinations and resolve issues while maintaining quality assurance metrics in a customer service-driven environment.

Highest-signal resume keywords

Grievance And Appeals ExperienceCustomer Service ExperienceData Entry SkillsExperience With Medicare PlansKnowledge Of Medical Terminology

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Medical Claims ProcessingAnalytic ReviewQuality AssuranceDocument ManagementData EntryMicrosoft Office SuitePart B Medical Pharmacy ClaimsAdministrative SupportProduction Goals AchievementInterpreting Procedures

Soft Skills

Interpersonal SkillsCompassionate InteractionProblem-SolvingFlexibilityContinuous Improvement Mindset

Tools & Technologies

PaHubRemote Work ToolsDocument Tracking Systems

Industry Keywords

Healthcare IndustryPharmaceutical IndustryMedicareDual Eligible Medicare/MedicaidGeriatric PopulationPHI/HIPAA Compliance

About the role

Key responsibilities & impact

Manage member and provider Part B denials and concerns
Conduct comprehensive analytic reviews of clinical documentation
Determine whether a grievance, appeal or further request is warranted
Deliver final determinations using trained skills and partnerships with clinical and other Humana teams
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
Meet company and department production goals and quality assurance metrics
Make decisions regarding methods, tactics and processes for administrative tasks and projects
Prioritize requests and interpret and adapt procedures, processes and techniques
Perform advanced administrative and customer support tasks independently

Requirements

What you’ll need

1 or more years of customer service (i.e. call center or retail) experience
Experience in the healthcare industry, pharmaceutical industry or medical field
1 or more years of grievance and appeals (G&A) experience
Experience in a production and quality assurance driven environment
Strong data entry skills including the Microsoft Office suite (Word and Excel)
Ability to work any day Sunday–Saturday, 8-hour shifts between 7 a.m. and 7 p.m. EST
Flexibility to work possible overtime based on business needs
Passion for continuously improving consumer experiences
Previous experience processing medical claims, ideally Part B Medical Pharmacy claims (preferred)
Experience with Medicare or dual eligible Medicare/Medicaid plans (preferred)
Knowledge of medical terminology (preferred)
Experience managing large volumes of documents, including tracking, copying, faxing and scanning (preferred)
Experience with PaHub for processing medical appeals (preferred)
Prior experience working in a remote/work-at-home environment (preferred)
Excellent interpersonal skills and ability to interact sensitively and compassionately with the geriatric population (preferred)
Minimum 25 Mbps download and 10 Mbps upload internet connection for home work
Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information

Benefits

Comp & perks

Medical, dental and vision benefits
401(k) retirement savings plan
Paid time off
Company and personal holidays
Paid parental and caregiver leave
Short-term and long-term disability
Life insurance
Personal wellness and smart healthcare decision support
Occasional travel to Humana's offices for training or meetings may be required