The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. You will perform advanced administrative/operational/customer support responsibilities that require independent initiative and judgment.
Assist members by phone to further/support quality related goals.
Investigate and resolve member and practitioner issues.
Decisions typically focus on methods, tactics and processes for completing administrative tasks/projects.
Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques.
Work independently with limited supervision, drawing on substantial experience of administrative responsibilities and organizational practices.
Use your skills to make an impact
Required Qualifications
Must reside in Puerto Rico.
Bilingual (English and Spanish); with the ability to read, write, and speak in both languages with no limitations or assistance.
Two (2) years of customer service experience.
Experience working in the healthcare industry or a medical field.
Experience working in a production driven environment.
Proficient in data entry and record management, maintaining accuracy while meeting productivity goals.
Intermediate experience with Microsoft Word and Excel.
Preferred Qualifications
Associate or bachelor's degree.
Previous inbound call center or related customer service experience.
Grievance and appeals experience.
Previous experience processing medical claims.
Prior experience with Medicare.
Experience with the Claims Administration System (CAS).
Knowledge of medical terminology.
Ability to manage large volume of documents including tracking, copying, faxing and scanning.
Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population.
Additional Information
Workstyle: This is a remote position.
Work Schedule: Monday through Friday, 8:00 a.m. to 5:00 p.m.; however, candidates must be flexible to adjust their schedule and work overtime as business needs require.
Start Date & Training Schedule: September 21 - Training will be conducted remotely and will last approximately 8–10 weeks. Attendance throughout the entire training period is mandatory, and we will not approve any time off requests during training. You must be available to fully participate in and successfully complete the training program as scheduled.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.About Us
About Humana: 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. Learn more about what we offer at Humana.com and at CenterWell.com.
Equal Opportunity Employer
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.
Skills Required
- Must reside in Puerto Rico
- Bilingual English and Spanish (read, write, speak) with no limitations
- Two (2) years of customer service experience
- Experience working in the healthcare industry or a medical field
- Experience working in a production-driven environment
- Proficient in data entry and record management, maintaining accuracy while meeting productivity goals
- Intermediate experience with Microsoft Word and Microsoft Excel
- Reliable home internet (minimum 25 Mbps download / 10 Mbps upload) and dedicated workspace to protect PHI/HIPAA
- Availability for mandatory remote training (approx. 8-10 weeks) and flexible schedule including potential overtime
- Associate or bachelor's degree
- Previous inbound call center or related customer service experience
- Grievance and appeals experience
- Previous experience processing medical claims
- Prior experience with Medicare
- Experience with the Claims Administration System (CAS)
- Knowledge of medical terminology
- Ability to manage large volumes of documents (tracking, copying, faxing, scanning)
- Excellent interpersonal skills for sensitive interactions with geriatric population
Humana Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Humana and has not been reviewed or approved by Humana.
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Healthcare Strength — Medical, dental, vision, supplemental health, and long-term care insurance are offered alongside on-site/virtual wellness resources and weekly paid well-being time, indicating a whole-person focus.
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Leave & Time Off Breadth — Paid PTO and holidays, volunteer time, and formal leave options such as parental and caregiver time provide broad time-away support. Adoption assistance and lactation rooms extend coverage for key life events.
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Retirement Support — A 401(k) with company match anchors long-term savings. Employer-matched emergency savings programs complement retirement planning.
Humana Insights
What We Do
At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first.
