Appeals Back End UM Admin Coordinator

Become a part of our caring community The Grievances and Appeals Representative 4 role in the Internal Review Team 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 partners. Key Responsibilities: Manage Level 1 appeal cases , ensuring accuracy, completeness, and compliance with CMS requirements Review clinical documentation to support appeal determinations and escalation decisions Coordinate with clinical teams and internal partners to finalize appeal outcomes Investigate and resolve member and provider issues with a focus on timely resolution Maintain high productivity and quality standards in a production-driven environment Ensure strict adherence to confidentiality and compliance regulations Independently prioritize and manage multiple high-volume case assignments Proactively embraces change and supports smooth transitions in a dynamic work environment Use your skills to make an impact Required Qualifications: 1+ year of grievance & appeals and/or customer service experience Strong data entry skills Proficiency in Microsoft Office Applications Experience in a production-driven environment Experience prioritizing and delivering multiple assignments Strong commitment to confidentiality and high-quality results Preferred Qualifications: Associate's or Bachelor's degree 2–4 years of grievance and appeals experience Medical claims processing experience Previous inbound call center experience Experience wi

Become a part of our caring community Become a valued member of Humana's Internal Review Team as a Grievances & Appeals Representative 2, where you will play a critical role in addressing client concerns and denials. You will perform thorough reviews of clinical documentation to assess whether grievances, appeals, or additional requests are justified. Then, you will provide final determinations utilizing your expertise and collaboration with clinical and other Humana teams. Your contributions will directly support Humana's commitment to delivering high-quality service and making a positive difference in the lives of those we serve. Must be passionate about contributing to an organization focused on continuously improving consumer experiences. Key Responsibilities: Assign cases to team members for submission to an independent entity for 2nd level review. Monitor and record the number of cases assigned to the team, as well as the distribution of cases among individual associates. Operate within established guidelines to maintain work expectations and quality standards, while exercising discretion in prioritizing tasks and managing timelines with minimal supervision. Demonstrate flexibility and resilience in adapting to evolving processes and a fast-paced work environment. Use your skills to make an impact Required Qualifications Minimum of 1 year of customer service experience Minimum of 1 year of data entry experience Experience in a production-driven environment Must have strong experience using multiple Microsoft systems simultaneously (Teams, SharePoint, Excel, etc.) Ability to manage large volume on inventory daily Preferred Qualifications Previous inbound call center or related customer service experi

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary Risk Management is charged with protecting company assets. This group is responsible for minimizing risk – in legal, financial and operational areas – and its affects on the organization, as well as for enforcing security and safety measures. Coordinate effective resolution of member and/or provider/practitioner appeals, complaints and grievances. Responsible for the day-to-day management of staff to ensure effective resolution of member or provider/practitioner appeals, complaints and grievances for all products, which may contain multiple issues and, may require coordination of responses from multiple business units. Ensure timely, customer focused response to appeals, complaints and grievance. Responsible for day-to-day implementation of Aetna's appeals, complaints and grievances policies and procedures. Identifies trends and issues; reports on and recommends solutions. Accountable for meeting the financial, operational, and quality objectives of the unit. -Manages team's productivity and resources, communicates productivity expectations and balances workload to achieve customer satisfaction through prompt/accurate handling of customer concerns. -Serves as a content model expert and mentor to team regarding Aetna's policies and procedures, regulatory and accreditation req

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Job Profile Summary Leads automation and AI transformation strategy across the Payment Integrity, Revenue Integrity, and Grievances and Appeals COEs. Builds and manages a team to ideate, prioritize, and oversee delivery of automation and agentic AI initiatives that improve claims accuracy, recovery, and appeals outcomes. Partners with COE and business leadership to align automation roadmaps to enterprise priorities, governance standards, and measurable business impact. Job Description A Brief Overview Leads a team to drive automation and AI-enabled transformation across Payment Integrity, Revenue Integrity, and Grievances and Appeals. Sets strategic direction for how automation and intelligent workflow opportunities are identified and scaled across these COEs, and ensures successful, on-time delivery through strong program oversight. Balances delivery accountability with team development, ensuring the group operates as a cohesive practice rather than three disconnected initiatives. What you will do Leads and develops a team, setting priorities, allocating capacity across COEs, and holding the team accountable to delivery and quality standards. Sets the automation transformation strategy for Payment Integrity, Revenue Integrity, and Grievances and Appeals in partnership with COE leadership. <

Replit is the agentic software creation platform that enables anyone to build applications using natural language. With millions of users worldwide, Replit is democratizing software development by removing traditional barriers to application creation. Role Summary Replit is the agentic software creation platform that enables anyone to build applications using natural language. With millions of users worldwide, Replit is democratizing software development by removing traditional barriers to application creation. As a Disputes and Chargeback Program Manager at Replit, you’ll be part of our Trust and Safety Operations team, who owns customer-facing workflows that handle sensitive and policy-driven interactions across the Support organization. This includes areas such as privacy requests, DMCA and intellectual property claims, law enforcement requests, and abuse appeals. You'll own Replit's disputes and chargeback function end-to-end: from the individual case in front of you to the policies, playbooks, and automation that let it hold up as we scale to millions of users. This role combines strategic ownership with hands-on execution: you'll determine dispute and chargeback strategy, and build the systems that make those decisions repeatable at scale, working closely with Engineering, Legal and Finance. In this role you will… Own the full dispute lifecycle: investigate incoming chargebacks and disputes, decide whether and how to represent, gather evidence, and respond within network deadlines. Design and maintain the policies, decision trees, and SOPs that govern how disputes and chargebacks are handled. Define the key metrics, health targets, and goals for the disputes program and track performance against them, reporting to leadership. Monitor chargeback rates and dispute trends to identify the underlying drivers of volume, and partner with Engineering and Finance to address root causes. Partner with Engineering and Support Operations to automate manual parts of the wor

At Lyft, our purpose is to serve and connect. We aim to achieve this by cultivating a work environment where all team members belong and have the opportunity to thrive. We are looking for a detail-driven Legal Billing Specialist to join our growing Legal Operations Team. In this role, you will own the day-to-day of outside counsel and vendor billing across our matter management and eBilling platforms—reviewing invoices, enforcing our Outside Counsel Guidelines and negotiated fee arrangements, and keeping our legal spend accurate, compliant, and on time. The ideal candidate is tech-savvy, numbers-oriented, and thrives under recurring billing deadlines, bringing a collaborative and transparent approach to partnering with attorneys, law firms, and Finance. This is a billing-focused role that also supports the broader Legal Operations function. Responsibilities: Prepare, review, and process outside counsel and vendor invoices; audit prebills and invoices, and flag rate errors, block-billing, math discrepancies, and billing-guideline violations before approval. Manage the day-to-day operation of the eBilling and matter management platform (Onit), including invoice intake, LEDES processing, rejections and appeals, accruals, and international / AP invoice processing. Enforce compliance with Lyft’s Outside Counsel Guidelines (OCG) and negotiated fee and alternative fee arrangements (AFAs); process write-offs, write-downs, and adjustments with clear documentation and audit trail. Manage timekeeper and billing-rate submissions and approvals; maintain accurate rate cards, matter budgets, and phase/task coding across the portfolio. Serve as the primary point of contact for billing inquiries and disputes; resolve discrepancies promptly by partnering with attorneys, law firms, and support staff. Partner closely with the Legal Operations eBilling Lead and with Finance / Accounts Payable on accruals, month- and quarter-end close, reconciliation, and payment status. Onboard outside