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The Director, Grievances & Appeals manages the client medical denials experience through organization and delivery of supporting structures, allowing for effective and comprehensive analytic review in a timely manner to provide resolutions for Humana membership. The Director, Grievances & Appeals requires an in-depth understanding of how organization capabilities interrelate across the function or segment and are managed to deliver best results within detailed requirements.

The Director, Grievances & Appeals assists members and providers, via multiple channels to support final resolution within compliance timeframes and guidelines related to support and quality related goals.

The Resolution Team handles all complaints for Humana, including formal grievances, appeals, and inquiries escalated to our executives. Our mission is to resolve these complaints quickly, effectively, and with empathy. Additionally, we leverage customer complaints to continuously improve upstream processes, ultimately reducing the number of complaints received and improving our stakeholders’ experiences.

Currently undergoing a transformation in people, process, and technology, the Resolution Team aims to enhance quality, timeliness, and the overall experience for our associates, members, and providers. As the Resolution Team Operations Director, you will be accountable for the day-to-day operations and performance of various complaint types handled by the team.

Responsibilities - In this role, the Director will:

• Offer direction and leadership to various operational teams.

• Meet or exceed all operational goals, including regulatory compliance requirements.

• Promote and build an 'Audit Ready Every Day' culture.

• Simplify and improve processes across teams.

• Drive additional operational efficiencies.

• Collaborate with upstream business partners to identify opportunities and drive initiatives to reduce complaints.

• Work closely with and support other Resolution leaders to achieve overall team operational goals, including transformation strategy.

• Increase Stars scores by improving timeliness and decision-making.

• Lead by example to cultivate a climate of motivation, positive energy, and meaningful work.

• Assess, select, recognize, develop, and empower diverse talent.

• Guide and energize others, model adaptability, and inspire strong organizational performance during periods of transformation, ambiguity, and complexity.

• Ensure all grievance and appeal processes comply with federal and state laws, including CMS guidelines.

• Implement quality control measures to monitor the accuracy and timeliness of case handling by the team.

• Prepare for CMS program audits and maintain audit readiness.

• Develop and implement policies and procedures related to grievances and appeals.

• Recommend and implement process improvements to enhance member and provider satisfaction.

• Track key metrics related to grievance and appeals volume, trends, and resolution times.

• Generate reports for leadership to identify areas for improvement.

Use your skills to make an impact

Required Qualifications

• Undergraduate degree

• Minimum 7 years of extensive experience in leading large-scale, highly complex operations with proven results.

• Minimum 5 years of strong leadership experience managing teams, motivating staff, and fostering collaboration.

• Minimum 5 years of strong healthcare business acumen and comprehensive understanding of Medicare and/or State regulations.

• Proven ability to drive accountability and engagement at all organizational levels.

• Familiarity with relevant laws and regulations governing grievances and appeals, including CMS guidelines

• High emotional intelligence and excellent interpersonal, organizational, communication, and presentation skills.

• Strong analytical skills with the ability to analyze complex data, identify trends, and make sound decisions.

• Problem-solving skills to effectively address complex issues and resolve grievances and appeals.

• Financial savviness with the ability to manage staffing models and a multi-million-dollar budget.

• Operational mindset with experience leading processes and implementation.

Work-At-Home Requirements

• 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 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

Preferred Qualifications

• Master’s Degree

• Reside near Louisville, KY area

• Experience with Medicare Appeals

• Experience with Appeals and understanding of claims, CMS/State requirements, and Stars impact.

• Experience leading large cross-functional teams in a high-stress, compliance-focused environment.

Additional Information

• Must be willing to travel to Louisville, KY based on business if residence is outside of the area

• The Director of Grievances and Appeals plays a crucial role in ensuring member satisfaction and regulatory compliance. This position requires a strategic thinker with a passion for operational excellence and team leadership. If you are dedicated to driving meaningful change and improving the member experience, we encourage you to apply.

• As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.

• If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews. This is a remote role - #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.

$126,300 - $173,700 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: 02-27-2025

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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.