Director – G&a Internal Review Team

Become a part of our caring community and help us put health first
 

As part of Humana’s Resolution Team, the Director of Grievances and Appeals is responsible for overseeing the management of Level 1 and Level 2 Medicare appeal processes within the organization. This role ensures compliance with Medicare regulations and strives to drive five-star performance for related CMS metrics.

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, our goal is to leverage insights to improve upstream processes and policies, ultimately reducing preventable appeals and providing an improved customer experience.

Leading a team of 5-10 direct reports and managing approximately 100-200 full-time employees, the Director drives operational excellence and fosters a culture of accountability and continuous improvement. This position ensures all processes are efficient, accurate, and aligned with regulatory requirements while collaborating with stakeholders to address issues and enhance member satisfaction.

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:

• Provide Strategic Leadership
  • Offers direction and leadership to various operational teams
  • Meets or exceeds operational goals ensuring compliance requirements are met
  • Oversees performance for two Star measures driving 5-star performance
  • Promotes and builds an 'Audit Ready Every Day' culture​
• Operational Excellence
  • Simplifies and improves processes across teams
  • Drives additional operational efficiencies
  • Increases IRE Stars performance within the Resolution Team by improving timeliness and consistency in decision-making
  • Collaborates with upstream business partners to achieve 5 Star performance in the CMS IRE measures by identifying opportunities and driving initiatives for improvement​
• Leadership and Culture
  • Leads by example to cultivate a climate of motivation, positive energy, and meaningful work
  • Assess, select, recognize, develop, and empowers diverse talent
  • Guides and energizes others, models adaptability, and inspires strong organizational performance during periods of transformation, ambiguity, and complexity​
• Compliance and Quality Assurance
  • Implements quality control measures to monitor the accuracy and timeliness of case handling by the team
  • Prepares for CMS program audits and maintain audit readiness​
• Policy Development and Process Improvement
  • Develops and implements policies and procedures related to grievances and appeals
  • Recommends and implements process improvements to enhance member and provider satisfaction

In addition to being a great place to work, Humana also offers industry leading benefits for all employees, starting your FIRST day of employment. Benefits include:

• Medical Benefits
• Dental Benefits
• Vision Benefits
• Health Savings Accounts
• Flex Spending Accounts
• Life Insurance
• 401(k)
• Parental leave, caregiving leave, and weekly well-being time

And more

Use your skills to make an impact
 

Required Qualifications

• Master’s or post-graduate degree ie. JD, PhD, etc.

• 10+ years' Leadership experience leading large cross-functional teams in a high-stress environment

• Strong leadership skills with the ability to influence decisions across the enterprise to ensure 5 Star performance across IRE measures

• 4+ years' experience with the Medicare Appeals process and CMS’ Independent Review Entity

• 4+ years' experience with CMS/State requirements and Stars impact

• Comprehensive understanding of Medicare regulations and Stars measures

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

• 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

• ​Operational mindset with experience leading processes and implementation

Additional Information

​Location and Availability:

• Reside near Louisville, KY area - this will be a Hybrid role - home and office.

• Availability to work a scheduled 40-hour workweek.

Work at Home/Remote Requirements

Work-At-Home Requirements

• To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended to support Humana applications, per associate.
  • Wireless, Wired Cable or DSL connection is suggested.
  • Satellite, cellular and microwave connection can be used only if they provide an optimal connection for associates. The use of these methods must be approved by leadership.  (See Wireless, Wired Cable or DSL Connection in Exceptions, Section 7.0 in this policy.)
  • Humana will not pay for or reimburse Home or Hybrid Home/Office associates for any portion of the cost of their self-provided internet service, with the exception of associates who live or work from Home in the state of California, Illinois, Montana, or South Dakota.  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

Our Hiring Process

As part of our hiring process, we will be using an exciting interviewing technology provided by HireVue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging, and/or Video Interview.  If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone or computer. You should anticipate this interview to take approximately 10-15 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

If you have additional questions regarding this role posting and are an Internal Candidate, please send them to the Ask A Recruiter persona by visiting go/Buzz and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.

Alert:  Humana values personal identity protection.  Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file.  When required, an email will be sent from [email protected] with instructions to add the information into the application at Humana’s secure website.

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Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

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 yearThis 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.

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.

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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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.