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The Manager, Grievance and Appeals ensures that products meet certain standards of quality and ensure compliance and production metrics are met. The Manager, Grievance and Appeals works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules, goals and helps to align on and drive department strategy.

The Manager, Grievance and Appeals is responsible for leading and guiding a team of leaders and associates in delivering service and operational excellence. The Manager will help to drive the investigation and resolution of member and practitioner issues. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. This role requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

• Find ways to improve the organization’s efficiency and accuracy related to Medicare Part C/D Grievance and Appeals and to minimize compliance risk exposure to the company

• Gather data from various sources and look for patterns and trends

• Perform deep-dive analyses to identify root cause failures and develop remediation action plans

• Collaborate with stakeholders including business partners, SMEs and Leadership to find process efficiencies for upstream and downstream processes and improve business performance/drive results

• Support short- and long-term operation/strategic business activities through analytics

• Interact one-on-one and consult with all levels of leadership

• Effective at working at both a data detail level and a strategic thinking level

• Analyze and interpret reports on metrics associated with goals and objectives

Use your skills to make an impact

Required Qualifications

• 5 or more years of equivalent work experience in Grievance and Appeals (G&A)

• 3 or more years of leadership experience

• Strong knowledge of Medicare and Medicaid standards and regulations

• Knowledge of WorkForce Management systems and processes

• Ability to monitor and recommend improvements to improve team compliance, quality and productivity by providing expert advice and assistance to others

• Strong attention to detail, organizational and analytical skills with the ability to manage multiple priorities and/or projects

• Excellent communication and presentation skills to include the ability to communicate and present technical details to senior and/or executive level leadership

• Proficient in Microsoft Excel with the ability to perform advanced functions

• Must be able to work within Eastern Standard Time (EST) business hours

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

Preferred Qualifications

• Experience in leading large teams (I.E. 50 or more associates) and/or leading leaders (Supervisors, Team Leads etc...)

• Bachelor’s Degree in Business, Finance, Healthcare, or related field

• 1 or more years of experience conducting Root cause Analysis (Within a healthcare industry environment) and providing insights/findings to Senior Leadership

• Working experience with Power BI and/or Tableau

• Previous auditing experience

• Knowledge of or experience with health and business data and informatics

• Bilingual (English and Spanish), must be able to read, write and speak

Additional Information

Work Style : Remote

Work Days/Hours : Monday – Friday; must be able to work an 8 hour shift sometime between the hours of 8 a.m. – 5 p.m. Eastern Standard Time (EST). Additional hours may be required for business need.

HireVue Statement : As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

Work at Home/Remote Requirements

To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense

• Humana will provide Home or Hybrid Home/Office associates with telephone and computer equipment appropriate to meet the business requirements for their position/job

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

This is a remote position

#LI-Remote

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.

$86,300 - $118,700 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. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides 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 and many other opportunities.

Application Deadline: 02-07-2025

About us

About CarePlus Health Plans: CarePlus Health Plans is a recognized leader in healthcare delivery that has been offering Medicare Advantage health plans in Florida over 23 years. CarePlus strives to help people with Medicare, or both Medicare and Medicaid, achieve their best possible health and wellness through plans with benefits and services they care about. As a wholly owned subsidiary of Humana, CarePlus currently serves Medicare beneficiaries throughout 21 Florida counties.

About Humana: Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers, and our company. Through our Humana insurance services, and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.