Job Title

Become a part of our caring community and help us put health first The Manager, Home Health Grievances & Appeals 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 Manager, Home Health Grievances & 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 and goals. The Manager of Grievance and Appeals guides the overall audit, appeal and review process to preserve and recover revenue while maintaining the highest level of clinical and regulatory integrity and compliance. Provides direction and oversight to ensure appropriate and supportive documentation is submitted completely and efficiently and meets all regulatory and billing compliance. Uses clinical expertise to direct and guide agencies and staff through all selected CMS audits, initiatives and demonstration projects. Essential Functions: u2022 Provide direction and support to the clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects. u2022 Collaborates with clinical and operational leadership in the development of an education plan to improve processes to preserve and recover revenue. u2022 Directs orientation for new staff both within the department and at the branch level (as needed) to assure audit, appeals and any medical record review process flows are within company standards. u2022 Monitors, trends and analyzes data to assist in developing plans to improve clinical documentation to ensure regulatory compliance to safeguard or recoup earned revenue. u2022 Directs workflow process and assignments to ensure all audits, appeals and reviews are submitted timely for preservation of revenue and/or reimbursement. u2022 Directs audit activity leads the development of appeal strategies and review responses. u2022 Directs the review of medical records and the various levels of appeals in preparation for and participation in Administrative Law Judge hearings. u2022 Directs the regional managers to ensure audit, appeal and review processes are in place and effectively and efficiently implemented at the branch level. u2022 Directs the use of select EMR database information and the audit and denial management software. u2022 Directs the evaluation of agency readiness for all CMS audits and initiatives and guides the education at the agency level. u2022 Assist in promoting compliance with federal, state and local regulatory agencies. u2022 Protect the integrity of the organization, patients and co-workers by maintaining confidentiality of all patient and business information. u2022 Maintain and contribute to the efficiency of operations by consistently complying with all policies, procedures and guidelines of the company. u2022 Perform all job responsibilities with a friendly, positive and team-oriented attitude. u2022 Ensure compliance with all Company policies/procedures as related to Medicare billing practices and overall clinical operations. u2022 Participate in special projects and perform other duties as assigned Use your skills to make an impact Required Qualifications + Thorough knowledge of health care policy, industry and related clinical practice + Project management principles and clinical policy development/implementation + Knowledge of all Medicare regulations and appeals processes + Analytical skills with ability to interpret and apply regulatory requirements + Excellent verbal/written communication and presentation skills + Knowledge of Payer requirements, ADR requests, Denials, Appeals, RAC/ZPIC and CERT responses + Must be able to work well independently and in a team environment + Excellent communication and organizational skills + Strong attention to detail + Must read, write and speak fluent English. + Must have good and regular attendance. + Approximate percentage of time required to travel: 20% + Performs other related duties as assigned. + Bachelor or Associate degree in Nursing or Other Health Care related fields + Professional License in current state of residence + Minimum 5 yearsu2019 experience in health care management Preferred Qualifications + 10 years in Medical Certified home health care preferred + Healthcare industry experience preferred Additional Information 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. $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, u201cHumanau201d) 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: 03-30-2026 About us About CenterWell Home Health: CenterWell Home Health specializes in personalized, comprehensive home care for patients managing a chronic condition or recovering from injury, illness, surgery or hospitalization. Our care teams include nurses, physical therapists, occupational therapists, speech-language pathologists, home health aides, and medical social workers u2013 all working together to help patients rehabilitate, recover and regain their independence so they can live healthier and happier lives. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nationu2019s largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first u2013 for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. u200b 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.Centerwell, a wholly owned subsidiary of 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 full accessibility rights information and language options