投诉与上诉快速案件代表
Grievances & Appeals Expedited Case Rep
成为我们关怀社区的一员
投诉与上诉代表3负责处理加速的医疗补助和AIP（双重）上诉案件，并审查临床文档以确定是否需要上诉。这是一个高工作量、快节奏的职位，每小时需处理多个案件。您需要具备主动的队列管理能力，有跨多个工作流处理支持请求的经验，能够适应变化的流程，并能与经理和团队负责人进行有效沟通。您将向投诉与上诉主管汇报。
作为投诉与上诉代表3，您将：
- 每小时审查和评估多个加速的医疗补助和AIP（双重）案件。工作量会根据实际情况变化，因为这是一个持续高工作量的职位。
- 从分配到解决全程管理案件，对临床文档进行分析性审查，并与业务合作伙伴协作完成调查。
- 评估案件的紧急程度，并按时间顺序处理案件，确保在严格的处理时限内（通常为24小时）完成。
- 对每个案件进行外拨电话，向客户或提供者传达结果，或请求文档、澄清案件细节或解决未决问题。
- 及时了解频繁更新的指导文件和工作流程。
- 监控多个工作流并快速适应流程变化。
- 在发现差距或问题时进行沟通，并在需要时寻求指导。
运用您的技能产生影响
所需资格
- 1年以上客户服务经验
- 1年以上医疗保健行业或医学领域的经验
- 必须有生产经验和达成绩效指标的经验
- 熟悉微软办公软件（包括Word、Excel、Outlook和Teams），并能在多个软件系统中工作
- 有管理高工作量、快速变化的工作任务的经验，能够独立工作，管理不断变化的优先级，并适应新流程而不受影响
优先资格
- 之前有呼叫中心或相关客户服务经验
- 有投诉与上诉经验
- 有处理医疗授权的经验
- 具备英语和西班牙语双语能力，能够阅读、书写和口语交流英语和西班牙语
- 有医疗保险或医疗补助经验
- 熟悉医学术语
所需培训安排：
- 虚拟培训将在第一天开始
查看英文原文
Become a part of our caring community
The Grievances & Appeals Representative 3 works expedited Medicaid and AIP (dual) appeals cases and reviews clinical documentation to determine if an appeal is warranted. This is an extremely high-volume, fast-paced role, with the responsibility of moving several cases per hour. You will need to have proactive queue management, experience handling support requests across multiple workstreams, ability to adjust to changing processes, and effective communication with managers and team leads. You will report to the Grievances & Appeals Supervisor.As a Grievances & Appeals Representative 3, you will:
- Review and evaluate several expedited Medicaid and AIP (dual) cases per hour. Caseload volume varies as it is a consistently significant high-volume role.
- Manage cases from assignment to resolution, conducting analytic reviews of clinical documentation and collaborating with business partners to complete investigations.
- Assess case urgency and process cases in chronological order, ensuring resolution within strict turnaround times (typically 24 hours).
- Make outbound calls on every case to deliver outcome to members or providers, or request documentation, clarify case details or address outstanding issues.
- 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.
Use your skills to make an impact
Required Qualifications
- 1+ years of customer service experience
- 1+ years of experience in the healthcare industry or medical field
- Must have experience with production and meeting performance metrics
- Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems
- Experience managing a high-volume, rapidly changing workload while remaining self-sufficient, managing shifting priorities, and adapting to new processes without disruption
Preferred Qualifications
- Previous inbound call center or related customer service experience
- Prior Grievances and Appeals experience
- 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
- Knowledge of medical terminology
Required Training Schedule:
- Virtual training will start day one and will last for approximately four (4) weeks. Training will be held Monday through Friday and will follow a schedule between 8:00 am – 5:00 pm Eastern Time. Training hours will be communicated prior to the start date.
- Attendance is vital for success; no time off is allowed during training and is limited within the first 180 days.
Required Work Schedule:
- Following training, must be able to work 11:30 am – 8:00 pm Eastern, Tuesday through Saturday, with alternating holidays and overtime as needed.
- Hours are subject to change based on business needs.
- Must commit to working within the department for a minimum of eighteen (18) months.
Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.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.$43,000 - $56,200 per yearDescription 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.Application Deadline: 10-01-2026
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.
Originally posted on Himalayas