Grievances & Appeals Professional

Become a part of our caring community   Join Humana's Wisconsin Medicaid team as a Grievances and Appeals Professional and make a meaningful impact in the lives of our members. Reporting to the Manager of Consumer Engagement, you will advocate for member rights and ensure fair treatment by reviewing clinical documentation thoroughly and resolving concerns with skill and integrity. You will collaborate with dedicated clinical experts and teams across Humana to deliver thoughtful final determinations on grievances and appeals.

Review, research, and help resolve formal grievances, appeals, informal complaints, and member concerns following applicable requirements and deadlines. Ensure concerns are handled fairly, thoroughly, and with appropriate documentation to support member rights. Investigate member and practitioner issues by gathering relevant information, reviewing case details, and identifying appropriate next steps. Collaborate with clinical reviewers, internal partners, and teams to evaluate documentation and support accurate final determinations. Help with conflict resolution and mediation efforts to address concerns in a respectful, and solution-focused manner. Document findings, actions, and outcomes to support case resolution and regulatory expectations. Help identify trends, process opportunities, or recurring issues that may influence the member experience. Maintain confidentiality and handle sensitive member information. Use your skills to make an impact   Required Qualifications Bachelor's degree 3+ years of experience in social work, human services, healthcare, medical services, or a related field 2+ years of experience using Microsoft Word and Excel, including organizing, tracking, and manipulating data Demonstrated ability to work independently, manage multiple assignments or cases simultaneously, and meet established deadlines, turnaround times, or compliance requirements Preferred Qualifications Experience with grievances and appeals processes, procedures, or case resolution Experience working with Medicaid or Medicare populations Experience processing medical claims or applying medical terminology Experience supporting individuals with intellectual/developmental disabilities, physical disabilities, or frail elder populations Additional Information Workstyle: remote, work from home Travel: potential for travel 1-2 times per year Typical Workdays/hours: Monday – Friday, between 8:00 am – 5:00 pm CST 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 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.   $59,300 - $80,900 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.