Grievances & Appeals Expedited Case Rep

📋 Description

• • Review and evaluate multiple expedited Medicaid and AIP (dual-eligible) appeals cases per hour in a high-volume, fast-paced environment.
• • Manage cases from assignment to resolution by analyzing clinical documentation and collaborating with business partners to complete investigations.
• • Assess case urgency and process all cases in chronological order to meet strict 24-hour turnaround requirements.
• • Make outbound calls on every case to communicate outcomes to members or providers, request missing documentation, clarify details, or resolve outstanding issues.
• • Monitor and adapt to multiple concurrent workstreams, adjusting quickly to frequent changes in processes, mentor documents, and workflows.
• • Maintain compliance with HIPAA regulations by working from a dedicated, interruption-free space to safeguard member PHI.
• • Meet and exceed performance metrics in a production-driven environment with shifting priorities and high workload demands.
• • Stay current with evolving company policies, procedures, and system updates without disruption to case processing timelines.
• • Communicate gaps, ambiguities, or operational issues to supervisors and seek timely guidance to ensure accurate case resolution.
• • Work a scheduled shift of 11:30 am – 8:00 pm (in CST/EST time zone), Tuesday through Saturday, with alternating holidays and occasional overtime as needed.
• • Complete a four-week, full-time virtual training program (Monday–Friday, 8:00 am – 5:00 pm CST/EST) starting June 29th, with no time off permitted during training.
• • Commit to remaining in the role for a minimum of 18 months post-training.
• • Utilize Microsoft Office Suite (Word, Excel, Outlook, Teams) and multiple software systems to track, update, and resolve cases efficiently.
• • Operate in a fully remote capacity with Humana-provided telephone equipment; internet must meet minimum 25 Mbps download and 10 Mbps upload speeds.
• • Residents of Illinois, Montana, or South Dakota will receive a bi-weekly internet expense stipend.
• • Occasional travel to Humana offices may be required for training or mandatory meetings.