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Appeals Specialist


This is a Full-time position in Charleston, WV posted September 13, 2021.


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 focus 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, andworks under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.

Required Qualifications

  • 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
  • Strong communication skills both written and verbal
  • 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
  • This position offers various shifts both during the week and on weekends. Shifts available are based on business needs. Shift specifics will be communicated during the applicant screening process.
  • Schedule will be centered around Eastern Standard Time hours.  Holidays may be required.
  • Flexibility – ability to work overtime and weekends, based on business needs
  • Must be passionate about contributing to an organization focused on continuously improving consumer experiences
  • Associates working in the state of Arizona must comply with the Tobacco Free Hiring Policy (see details below under Additional Information) and upon offer will be subjected to nicotine testing as part of a 10-panel drug test

Work-At-Home Requirements

  • 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 10×1 (10mbs download x 1mbs upload) for optimal performance is required

Job Requirements:

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

Additional Information

  • Must commit to working within the department for minimum of eighteen (18) months
  • Training:  Humana offers virtual training for the first 5-weeks following start.  Attendance is vital for your success.
  • At Humana, we know your well-being is important to you, and it’s important to us too. We are committed in making resources available to you that will enable you to become happier, healthier, and more productive in all areas of your life. If you share a real passion for helping people, we likely have the right place for you at Humana. The following policy applies only to associates working in the state of Arizona: We are committed in providing a safe and healthy work environment and to promoting the health and well-being of its associates. Effective July 1, 2011, we have adopted a tobacco-free hiring policy that will promote a healthier workplace and will not hire users of tobacco and nicotine products. If you have any questions, please consult with your recruiter.

Scheduled Weekly Hours


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