Grievances And Appeals Representative in United States

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. 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 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. 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

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

Become a part of our caring community Humana is looking for Inbound Contacts Representatives to be a part of our Provider Call Center; you are often the first human connection our members have with us. Working remotely, you will report to the Inbound Contacts Supervisor and be a part of the Medicare team. Every interaction is an opportunity to solve a problem, reduce frustration, and create trust. You will support members and providers by answering benefit questions, resolving concerns, and guiding them through next steps, helping ensure they feel informed and supported. This role is ideal for someone who enjoys helping others and takes pride in delivering a high-quality customer experience. As an Inbound Contacts Representative 2, you will: Handle 40&#43; inbound calls daily from providers in a back-to-back call center environment Address multiple members and provider needs, including benefit questions, service issues, and general inquiries Escalate unresolved and pending customer grievances Document all interactions, actions taken, and outcomes in internal systems Resolve routine to moderately complex issues by following established guidelines and workflows Identify issues requiring escalation and ensure handoff to the appropriate teams Meet quality, productivity, and customer experience expectations What Success Is: Providers feel heard, supported, and satisfied with their experience You are proactive and resolve issues on the first contact whenever possible Documentation is complete, clear, and compliant Experience empathizing with frustrated customers, and accountability in every interaction Use your skills to make an impact Required: 2&#43; years of Customer Service experie