Grievances And Appeals Rep Jobs

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. <

Become a part of our caring community The Medical Director, National Outpatient Medicare leverages clinical expertise and medical judgment to review preauthorization requests for services. This role is responsible for evaluating moderately complex to complex cases, where analysis of clinical information and situational factors requires in-depth assessment and sound decision-making. As a Medical Director at Humana , you will use your clinical expertise and judgment to make meaningful coverage and care determinations that support quality, consistency, and compliance across the healthcare continuum. In this role, you will review requests for services, level of care, and site of service, using nationally recognized clinical guidelines, CMS policies, medical references, and internal clinical resources to guide decision-making. This position offers the opportunity to work on complex outpatient cases , review clinical documentation, and collaborate with both internal partners and external physicians to gather additional information and discuss determinations. You may also contribute to care management activities and, depending on the role, provide input on areas such as clinical documentation, coding, grievances and appeals, and outpatient services or equipment reviews. Beyond case review, this role provides the opportunity to build strong relationships with physicians, provider groups, facilities, and community partners in support of regional priorities. It is a strong fit for physicians who are interested in contributing to value-based care, population health, and care management strategies while working in a structured environment that values sound clinical judgment, collaboration, and operational excellence. Humana is seeking a Medical Director to

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 The Senior Manager, Medicare Product Operations (NCOD) is responsible for providing leadership, operational oversight, and people management for the Non-Clinical Organization Determination (NCOD) team. This leader is accountable for ensuring accurate, timely, compliant, and member-centered coverage determinations while maintaining adherence to CMS regulations, and internal policies. The role oversees a team of managers and analysts responsible for evaluating member requests, issuing organization determinations, maintaining documentation, and supporting appeals- and grievance-related activities. This position serves as a key operational leader, driving quality, compliance, performance, process optimization, workforce development, and cross-functional collaboration. The Senior Manager partners with Compliance, Product, Appeals, Grievances, Eligibility, Technology, and vendor partners to ensure operational excellence and a best-in-class member experience. Responsibilities Include: Strategic Leadership Provides oversight for the NCOD operation, ensuring alignment with organizational goals, regulatory requirements, and member experience objectives. Establishes operational strategies, and performance standards that support long-term scalability and sustainability. Leads implementation of new NCOD workflo

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 Aetna Better Health is Aetna’s Medicaid managed care plan. Backed by over 30 years of experience managing the care of those with a broad array of health care needs, our Medicaid plans have demonstrated that getting the right help when you need it is essential to better health. That’s why Aetna® Medicaid plans include the guidance and support needed to connect our members with the right coverage, resources, and care. We are focused on enhancing quality and population health outcomes while integrating CVS assets to bring accessible healthcare to our members. Aetna Better Health of Maryland is seeking an experience leader with vast operational knowledge of Medicaid for its state-wide managed Medicaid business in the role of Chief Operations Officer (COO). The COO role will be strategic and committed to developing colleagues as well as relentlessly pursuing change that is best for the organization and its customers. The COO role will collaborate with the CEO to develop the strategic vision of the Health Plan, policies & procedures, and operational objectives including leading RFP readiness efforts. The COO will oversee high level strategic and operational activities of various plan functional areas which include traditional service operations (Claims, Provider Services, Information Technology, Grievance & Appeals and Member Services) as well as Medical Management (Quality, Netw

Handling Customer Grievances and Complaints. Customer care executives also need to handle complaints about defective products, Customer Support Executive plays a pivotal role in managing customer satisfaction and ensuring that issues are promptly and efficiently resolved. Positioned .

Dealing with unhappy customers and handling complaints is an almost inescapable duty of many customer Handling Customer Grievances and Complaints. Customer care executives also need to handle complaints about defective products,

Manager– HRBP Roles and Responsibilities Role: The Manager– HRBP is responsible for partnering with FWD teams at Myntra. Responsible for building a strong HR relationship with stakeholders, drive performance management, engagement, compliance of HR practices and guidelines. The associate will understand requirements of business (data/queries) offering solutions. Human Resources Business Partners work closely with management to increase the organizational health of the business. Provide leadership in the implementation and execution of related policies and guidelines; organizational design; company culture and employee development. would influence and partner with other groups around the company (legal, finance, recruiting, etc.) to advocate for business needs. HRBP also consult with employees and managers to address employee grievances and issues with a systematic approach. HRBPs participate in company-wide initiatives and programs while meeting the needs of their businesses. Key skills and abilities of a HRBP include coaching, consulting, facilitation, influencing, communication, process development, analysis and problem solving. Responsibilities: Generalist: ? To be a catalyst with Business to drive HR policies &amp; processes. ? To understand business environment &amp; priorities ? Work with business to address management requests for analysis on payroll cost, leaves, performance etc. ? To ensure that the sensitive issues are handled effectively and are brought to a logical conclusion with constant communication to relevant stakeholders Performance Management: ? To drive the philosophy for PMS as defined in the process ? Manage the execution of performance management e.g. annual and mid year promotions, feedbacks with Time line adherence ? Handling grievance on cases to cases basis and informing relevant stakeholders Resource Management: ? Ensuring personnel information is maintained in all appropriate systems; monitor actual

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 Omnicare is a leading provider of pharmacy services to long-term care facilities nationwide, supporting skilled nursing facilities, assisted living communities, and other institutional care settings. Following the sale of Omnicare by CVS Health, this role will support Omnicare and its continued operations as an independent, standalone organization. Candidates should be aware that this role will not remain within CVS Health following the transaction and be supporting approximately 6,000 colleagues. The individual hired into this role will be employed by Omnicare and will contribute to shaping the future of our organization during this exciting period of growth and transformation. Coordinates employee relations programs to ensure compliance with policies and practices. Develops and implements policies and procedures, including grievance procedures and exit interviews. Researches and responds to employee questions, concerns and grievances. Maintains employee relations records. Primary Job Duties & Responsibilities Develops complex policies and procedures related to employee relations, ensuring compliance with applicable laws and regulations. Under minimal supervision, serves as a point of contact for employees regarding workplace issues, conflicts, and concerns. Conducts investigations, gathers relevant information, and r

Who we are About Stripe Stripe is a financial infrastructure platform for businesses. Millions of companies - from the world’s largest enterprises to the most ambitious startups - use Stripe to accept payments, grow their revenue, and accelerate new business opportunities. Our mission is to increase the GDP of the internet, and we have a staggering amount of work ahead. That means you have an unprecedented opportunity to put the global economy within everyone's reach while doing the most important work of your career. About the team The Employee Relations and HR Compliance team, while relatively new at Stripe, is starting to scale! We are striving to build a respectful, balanced, well-skilled team focused on enabling the People team, managers, and Individual Contributors (ICs) to navigate challenging career moments while balancing compliance, empathy, and risk, resulting in success and engagement for all. What you’ll do We are looking for an Employee Relations & HR Compliance Specialist to join our team at Stripe. This individual will have well rounded HR experience and ideally expertise in employee relations. This person will be an instrumental part of the team, focusing on supporting our Employee Relations and HR Compliance Partners in EMEA and APAC to deliver excellence, improve and implement frameworks, guidelines, approaches, and best practices. The Employee Relations & HR Compliance Specialist will be highly cross functional and collaborative, partnering to inform and support Stripes and their managers. We anticipate the work to be split approximately 70%/30% between ER and HR Compliance initially. This is a full time contract role, with potential for extension. Responsibilities Employee Relations Support Partner with Employee Relations Partners to manage and resolve employee inquiries, concerns, and grievances effectively and discreetly. Conduct thorough investigations into employee complaints, working collaboratively to provide fair solutions in line

ABOUT THE ROLE We are seeking an organized, proactive, and collaborative Manager, International TMR to join our global People team. In this critical role, you will report to the Sr. Director, TMR and serve as the primary lead for employee relations matters across the EMEA region. You will contribute to the evolution of our proactive employee relations framework, focusing on risk mitigation through training, early conflict resolution, and data-driven insights. You will serve as a trusted subject matter expert, directly managing the investigation, documentation, and resolution of team member grievances, providing guidance on performance management, developing manager training programs, and offering specialized employee relations consultation. YOUR DAILY IMPACT AT PELOTON Investigation Management: Independently prioritize and manage an investigation caseload, balancing proper documentation, comprehensive interviews, stakeholder communication, concise fact-based report writing. Ensure all matters are handled with objectivity and urgency. Balance compliance with local employment laws, and company policy while maintaining a positive employee experience. Provide leadership with practical, high-judgment recommendations to enable sound and equitable decisions. Proactive ER: Synthesize and analyze case data and regional trends to identify early-stage issues. Drive proactive risk mitigation by providing leaders with actionable insights that improve organizational health and reduce legal exposure. Labor Relations: Serve as the subject matter expert for regional labor relations. Lead engagement and consultation processes as necessary to ensure compliance with local collective labor mandates. Performance Management: Provide expert guidance and coaching to people leaders on performance management processes. Ensure performance actions are legally defensible and strictly adhere to "fair process" standards across non-at-will jurisdictions. Stakeholder Partnership: Foster strong

The role is responsible for executing and overseeing tenant engagement initiatives, ensuring smooth interactions between tenants and stakeholders during redevelopment projects. This role involves supporting the role in securing tenant buy-in, managing grievances, and ensuring compliance with legal and regulatory frameworks. Source: Adani Group | Job ID: 55484

Opportunity Overview: We are looking for a dynamic and strategic HR Business Partner (HRBP) to join our People Operations team in India. This role will partner closely with business leaders to drive people strategy, enhance organizational effectiveness, and support a high-performance culture. The ideal candidate will bring strong HR generalist experience with deep exposure to business partnering, employee relations, performance management, and talent development within the Indian regulatory and cultural landscape. You should be a proactive problem-solver, an empathetic listener, and a trusted advisor who can balance business needs with employee well-being What you’ll do: You will work closely with leadership and cross-functional teams to align HR strategies with business goals. This role provides an opportunity to influence organizational growth and employee experience across key areas: Business Partnering: Partner with business leaders to understand goals and translate them into HR strategies Provide guidance on organizational design, workforce planning, and talent management Act as a trusted advisor on people-related matters Employee Relations: Manage employee grievances, disciplinary actions, and conflict resolution Ensure adherence to Indian labor laws and company policies Drive a positive and inclusive workplace culture Performance Management: Support goal-setting, performance reviews, and feedback processes Coach managers on performance improvement and employee development Identify high-potential talent and succession planning opportunities Talent & Engagement: Partner with Talent Acquisition for hiring strategies and workforce planning Partner with US People Business Partnership team to ensure solid communication and consistency of standards around talent and performance management Drive employee engagement initiatives, surveys, and action planning Support learning and development programs HR Operations & Compliance: Ensure compliance with Indian labo