Grievance and Appeals Manager - Humana
Santa Fe, NM
About the Job
Become a part of our caring community and help us put health first
The Manager, Grievances & Appeals manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Manager, Grievances & Appeals works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.
The Manager leads a team of Grievances & Appeals associates responsible for handling member inquiries and resolving member and practitioner issues. This role involves making decisions related to resource allocation, strategic approaches, and the tactical operations of departmental projects and initiatives. The position requires cross-departmental collaboration, including conducting briefings and area meetings, and maintaining regular contact with other managers across the department. The ideal candidate is self-directed, agile, and capable of driving change in a fast-paced, compliance-driven environment.
Use your skills to make an impact
Required Qualifications
+ 6 or more years of customer service experience
+ 2 or more years of Leading an Operational Team with Direct Reports
+ Must have experience in the healthcare industry or medical field
+ Strong data entry skills required
+ Advanced experience with Microsoft Word and Excel
+ Experience handling multiple projects and assignments as directed by Management
+ Capacity to maintain confidentiality and work independently in support of the department
+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
+ Bachelor's Degree – Preferred
+ More than 3 years of grievance and appeals experience
+ Strong knowledge in Microsoft Access or experience with SQL Server databases
+ Knowledge or experience with medical claims
+ Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
Additional Information
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
· Satellite, cellular and microwave connection can be used only if approved by leadership
· Associates 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 associates 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
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.
$84,600 - $116,300 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.
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.
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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
The Manager, Grievances & Appeals manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Manager, Grievances & Appeals works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.
The Manager leads a team of Grievances & Appeals associates responsible for handling member inquiries and resolving member and practitioner issues. This role involves making decisions related to resource allocation, strategic approaches, and the tactical operations of departmental projects and initiatives. The position requires cross-departmental collaboration, including conducting briefings and area meetings, and maintaining regular contact with other managers across the department. The ideal candidate is self-directed, agile, and capable of driving change in a fast-paced, compliance-driven environment.
Use your skills to make an impact
Required Qualifications
+ 6 or more years of customer service experience
+ 2 or more years of Leading an Operational Team with Direct Reports
+ Must have experience in the healthcare industry or medical field
+ Strong data entry skills required
+ Advanced experience with Microsoft Word and Excel
+ Experience handling multiple projects and assignments as directed by Management
+ Capacity to maintain confidentiality and work independently in support of the department
+ Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
+ Bachelor's Degree – Preferred
+ More than 3 years of grievance and appeals experience
+ Strong knowledge in Microsoft Access or experience with SQL Server databases
+ Knowledge or experience with medical claims
+ Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
Additional Information
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
· Satellite, cellular and microwave connection can be used only if approved by leadership
· Associates 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 associates 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
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.
$84,600 - $116,300 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.
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.
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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Source : Humana
