Job Description
Become a part of our caring community
Join Humana's Wisconsin Medicaid team as a Grievances and Appeals Professional and make a meaningful impact in the lives of our members. Reporting to the Manager of Consumer Engagement, you will advocate for member rights and ensure fair treatment by reviewing clinical documentation thoroughly and resolving concerns with skill and integrity. You will collaborate with dedicated clinical experts and teams across Humana to deliver thoughtful final determinations on grievances and appeals.Main Responsibilities:
- Review, research, and help resolve formal grievances, appeals, informal complaints, and member concerns following applicable requirements and deadlines.
- Ensure concerns are handled fairly, thoroughly, and with appropriate documentation to support member rights.
- Investigate member and practitioner issues by gathering relevant information, reviewing case details, and identifying appropriate next steps.
- Collaborate with clinical reviewers, internal partners, and teams to evaluate documentation and support accurate final determinations.
- Help with conflict resolution and mediation efforts to address concerns in a respectful, and solution-focused manner.
- Document findings, actions, and outcomes to support case resolution and regulatory expectations.
- Help identify trends, process opportunities, or recurring issues that may influence the member experience.
- Maintain confidentiality and handle sensitive member information.
Use your skills to make an impact
Required Qualifications
- Bachelor's degree
- 3+ years of experience in social work, human services, healthcare, medical services, or a related field
- 2+ years of experience using Microsoft Word and Excel, including organizing, tracking, and manipulating data
- Demonstrated ability to work independently, manage multiple assignments or cases simultaneously, and meet established deadlines, turnaround times, or compliance requirements
Preferred Qualifications
- Experience with grievances and appeals processes, procedures, or case resolution
- Experience working with Medicaid or Medicare populations
- Experience processing medical claims or applying medical terminology
- Experience supporting individuals with intellectual/developmental disabilities, physical disabilities, or frail elder populations
Additional Information
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Workstyle: remote, work from home
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Travel: potential for travel 1-2 times per year
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Typical Workdays/hours: Monday – Friday, between 8:00 am – 5:00 pm CST
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.$59,300 - $80,900 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.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.
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