Description

Become a part of our caring community
 

The Appeals Representative 4 is responsible for managing appeal denials, by reviewing clinical documentation, determining whether further action is needed, and validating final determinations in coordination with clinical and internal Humana partner. You will report to a Supervisor, Grievances & Appeals.

As the Appeals Representative 4 you will

• Managed Level 1 appeal cases, ensuring accuracy, completeness, and compliance with CMS requirements.
• Reviewed clinical documentation to support appeal determinations and escalation decisions.
• Coordinated with clinical teams and internal partners to finalize appeal outcomes.
• Investigated and resolved member and provider issues with a focus on resolution.
• Maintained high productivity and quality standards in a production-driven environment.
• Ensured strict adherence to confidentiality and compliance regulations
• Independently prioritized and managed multiple high-volume case assignments.
• Embrace change and support smooth transitions in work environment.

Use your skills to make an impact
 

Required Qualifications

• 1 or more years of Grievance & Appeals experience
• Strong data entry skills
• 1 or more years with Outlook (email and calendar management), Excel (data entry), Word (creating and editing documents) and Teams (meetings, chat, and file sharing)

Preferred Qualifications

• Associate Degree or higher
• 2 or more years of Grievance & Appeals experience
• Medical claims processing experience
• Previous inbound call center/customer service experience
• Experience with CAS and MedHOK
• Inventory management experience

This is a remote role and will provide coverage for Eastern time zone hours.

Training

• Virtual Training will start day one of employment and runs the first 6-8 weeks with a schedule of 8:00 AM – 4:30 PM EST, Monday – Friday.

Work Schedule Following Training

• Hours range 7am-7pm EST
• With Workforce Management to come it can vary between Sunday through Saturday if this helps.
• Must be flexible and able to work a variety of shifts, including weekends.
• Availability to work on Saturdays and Sundays may be required based on business needs.
• Candidates must be able to accommodate schedule changes based on business needs.
• Overtime and holiday work may be required based on business needs.

HireVue

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.

Work at Home

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.

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

40

Pay RangeThe 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.

 $48,300 – $65,900 per year

Description of BenefitsHumana, 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: 08-10-2026