Join Our Compassionate Team and Make a Difference in Health Care The Manager of Grievances & Appeals in Home Health Care Services is instrumental in managing client concerns and denials. This dynamic role involves conducting comprehensive analytic reviews of clinical documentation to assess grievances, appeals, and further requests, ultimately leading to informed final determinations through expert collaboration with our clinical teams. The Manager will operate within established guidelines, utilizing advanced technical knowledge to effectively address moderate complexity challenges. In this role, you'll supervise audit and review processes to safeguard and recover revenue while upholding the highest standards for clinical and regulatory integrity. You will provide essential guidance and support to our clinical and operational leaders, helping them navigate Medicare trends, denials, and CMS initiatives. Key Responsibilities: Advise clinical and operational leadership about Medicare audit trends and compliance. Collaborate to create educational programs that enhance processes for revenue preservation and recovery. Lead the onboarding process for new staff, ensuring adherence to compliant practices across departments and branches. Monitor and analyze data trends to improve clinical documentation and regulatory compliance. Direct prompt submission of audits and appeals to maintain revenue integrity. Develop and execute appeal strategies based on medical record evaluations. Oversee preparation for Administrative Law Judge hearings while guiding regional managers in effective audit processes. Leverage EMR databases and audit management tools to optimize operations. Assess agency readiness for CMS audits and provide educational support. Ensure compliance with all federal, state, and local regulations while upholding confidentiality. Contribute to operational efficiency by consistently adhering to policies and procedures. Foster positive interactions with colleagues, emphasizing teamwork and collaborative efforts. Ensure compliance with Medicare billing practices and the overall clinical operations framework. Engage in special projects and assume additional responsibilities as required. Your Qualifications: Strong foundational knowledge of health care policies and clinical practices. Familiarity with project management and the development of clinical policies. Comprehensive understanding of Medicare regulations and appeals processes. Excellent analytical skills for interpreting regulatory requirements. Exceptional verbal and written communication skills. Knowledge of payer requirements and strategies for managing denials. Proven ability to work both independently and collaboratively within a team setting. Outstanding organizational skills with keen attention to detail. Fluency in English, in reading, writing, and speaking. Consistent attendance and reliability in work performance. Willingness to travel approximately 20% of the time. Bachelor's or Associate's degree in Nursing or a related health care field. Professional license in the state of residence. A minimum of 5 years of experience in health care management. Preferred Qualifications: 10 years of experience in certified home health care. Broad experience in the healthcare industry. Additional Information: This position is primarily remote; however, occasional travel to Humana offices for meetings or training may be necessary. The standard work schedule is 40 hours per week. Compensation: The salary range for this position is $86,300 - $118,700 annually, commensurate with location, experience, and skill set. This role is also eligible for a performance-based bonus incentive plan. Our Commitment: At Humana, we offer comprehensive benefits designed to support holistic well-being, including medical, dental, and vision insurance, a 401(k) plan, generous paid time off, disability coverage, life insurance, and more. Application Deadline: 03-30-2026 About CenterWell Home Health: CenterWell Home Health specializes in providing personalized home care for patients managing chronic conditions or recovering from medical events. Our dedicated care teams consist of nurses, therapists, aides, and social workers, all working collaboratively to help patients achieve better health outcomes. Equal Opportunity Employer: Humana is committed to diversity and proactive hiring practices, ensuring no discrimination based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or veteran status.
