Job Information

Humana Grievance and Appeals Representative 3 in Torrance, California


The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if an a grievance, appeal or further request is warranted and then delivers final determination based on trained skillsets and/or partnerships with clinical and other Humana parties. The Grievances & Appeals Representative 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.


  • The Grievances & Appeals Representative 3 assists members, via phone or face to face, further/support quality related goals.

  • Investigates and resolves member and practitioner issues.

  • Decisions are typically focused on methods, tactics and processes for completing administrative tasks/projects.

  • Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.

Required Qualifications

  • High School Diploma

  • 1 - 3 years of customer service experience

  • Must have experience in the healthcare industry or medical field

  • Prior experience with Medicare

  • Previous experience processing medical claims

  • Strong data entry skills required

  • Intermediate experience with Microsoft Word and Excel

  • Must have experience in a fast-paced, production driven environment

  • Case management - ability to prioritize and manage inventory and work flow - strong attention to detail, organizational and time management skills

  • Department Hours: Must be able to work Thursday- Monday 8 -4:30pm EST based on business needs. Schedule will be centered around Eastern Standard Time hours. Holidays may be required.

  • Flexibility - ability to work overtime including weekends, based on business needs

  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences

  • Must ensure designated work area is free from distractions during work hours and virtual meetings

  • Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required

Preferred Qualifications

  • Associate's or Bachelor's Degree

  • Less than 2 years of leadership experience

  • Previous inbound call center or related customer service experience

  • Previous experience interpreting member benefits

  • 1 - 3 years of grievance and appeals experience

  • Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

  • Experience with the Claims Administration System (CAS)

  • Knowledge of medical terminology

  • Ability to manage large volume of documents including tracking, copying, faxing and scanning

  • Excellent interpersonal skills with ability to sensitively and compassionately interact with our members

Scheduled Weekly Hours