Grievances & Appeals Expedited Case Rep

Grievances & Appeals Expedited Case Rep

Employer: Humana. 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 - Must live in Central or Eastern time zone - 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 remai