[Remote] Grievances & Appeals Representative 2 - Medicaid

Note: The job is a remote job and is open to candidates in USA. Humana is a leading U.S. healthcare company focused on delivering care and services to millions. They are seeking a Grievances & Appeals Representative 2 to manage expedited Medicaid and AIP cases, requiring effective communication and analytical skills to determine case validity and meet strict turnaround expectations. Responsibilities • Review and evaluate several cases per hour by identifying valid expedited Medicaid and AIP (dual) cases. Caseload volume varies as it is a consistently significant high-volume role • Recognize urgent vs. routine cases and meet strict turnaround expectations (15–30 minutes) • Conduct analytic reviews of clinical documentation to determine case validity, including investigative work to find the denial • Make outbound calls to members or providers to verbally acknowledge receipt of valid cases • Work closely with leadership, who will assign cases to appropriate team contacts once your investigations are complete and validity is determined • Stay current with frequently changing mentor documents and workflows • Monitor multiple workstreams and adapt quickly to process changes • Communicate gaps or issues and seek guidance as needed Skills • 1+ years of customer service experience • Must have experience with production and meeting metrics • Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems • Associate or bachelor's Degree • Previous inbound call center or related customer service experience • Prior experience with grievance and appeals • Previous experience processing medical authorizations • Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish • Prior experience with Medicare or Medicaid • Experience with MHK, CGX, Guiding Care, and PA Hub • Knowledge of medical terminology Benefits • Medical, dental and vision benefits • 401(k) retirement savings plan • Time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave) • Short-term and long-term disability • Life insurance Company Overview • Humana is a health insurance provider for individuals, families, and businesses. It was founded in 1964, and is headquartered in Louisville, Kentucky, USA, with a workforce of 10001+ employees. Its website is http://www.humana.com. Apply To This Job Apply tot his job Apply To this Job