[Remote] Grievances & Appeals Representative 2 - Medicaid

Note: The job is a remote job and is open to candidates in USA. Humana is a leading U.S. healthcare company focused on delivering care and services to millions. They are seeking a Grievances & Appeals Representative 2 to manage expedited Medicaid and AIP cases, requiring effective communication and analytical skills to determine case validity and meet strict turnaround expectations. Responsibilities Review and evaluate several cases per hour by identifying valid expedited Medicaid and AIP (dual) cases. Caseload volume varies as it is a consistently significant high-volume role Recognize urgent vs. routine cases and meet strict turnaround expectations (15–30 minutes) Conduct analytic reviews of clinical documentation to determine case validity, including investigative work to find the denial Make outbound calls to members or providers to verbally acknowledge receipt of valid cases Work closely with leadership, who will assign cases to appropriate team contacts once your investigations are complete and validity is determined Stay current with frequently changing mentor documents and workflows Monitor multiple workstreams and adapt quickly to process changes Communicate gaps or issues and seek guidance as needed Skills 1+ years of customer service experience Must have experience with production and meeting metrics Intermediate experience with Microsoft Office programs (including Word, Excel, Outlook, and Teams) and comfortability working across multiple software systems Associate or bachelor's Degree Previous inbound call center or related customer service experience Prior experience with grievance and appeals Previous experience processing medical authorizations Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish Prior experience with Medicare or Medicaid Experience with MHK, CGX, Guiding Care, and PA Hub Knowledge of medical terminology Benefits 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 Company Overview Humana is a health insurance provider for individuals, families, and businesses. It was founded in 1964, and is headquartered in Louisville, Kentucky, USA, with a workforce of 10001+ employees. Its website is