Senior Grievances & Appeals Professional

Become a part of our caring community and help us put health first
 

The Senior Grievances & Appeals Professional analyzes and audits complaints received by the plan to ensure the integrity of claims, authorization processes, and business operations. You will report to the Associate Director, Grievances and Appeals, and be a part of the Resolution team.

As a Senior Grievances & Appeals Professional, you will:

• Analyze and audit complaints received by the plan to ensure the integrity of claims, authorization processes, and business operations.
• Utilize established process guidelines and industry knowledge to validate organizational decisions and assess downstream and upstream impacts
• Perform root cause analysis of audit findings and make recommendations for appropriate change management.
• Emphasize continuous improvement by identifying opportunities to reduce redeterminations, complaints, and rework of claims.
• Identify trends and areas of improvement resulting from information obtained through the Resolution team resources and available reporting/data.

Use your skills to make an impact
 

Required Qualifications:

• 5+ years of healthcare services experience in Sales, enrollment, Complaints to Medicare (CTMs) or equivalent G&A Professional role experience
• Prior auditing experience
• Experience using data analysis tools (such as Excel, SQL, or others) to create reports.
• Demonstrated knowledge using advanced features in Microsoft Excel, including data sorting, pivot tables, and complex formulas.
• Experience managing concurrent projects, maintaining thoroughly documented outcomes and minimal data entry error rates.

Preferred Qualifications:

• Bachelor's degree
• Experience with grievances, appeals, claims, authorization experience
• Knowledge creating Power BI reporting and analyzing data

Additional Information

Work-at-Home Information:

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.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay 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.

 

$65,000 - $88,600 per year

 

This 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.Application Deadline: 03-29-2026

About us
 

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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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.