Director, Home Health Grievances & Appeals

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

The Director Denials Management provides leadership for the audit, appeal and review process to preserve and recover revenue while maintaining the highest level of clinical and regulatory integrity and compliance. Manages the Denials Management data analytics, denial and appeal process.

The Director, Home Health Grievances & Appeals assists members, via phone or face to face, further/support quality related goals. Investigates and resolves member and practitioner issues. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, drives goals and objectives, and improves performance. Provides input into functions strategy.

Responsibilities:

• Oversee the process for direction and support to clinical and operational leadership regarding Medicare and governmental audit trends, denials, and any CMS initiative and/or demonstration projects.

• Collaborates with leadership team in the development of an education plan to improve processes to preserve and recover revenue.

• Analyzes region-wide outcome indicators to measure achievement of quantitative and qualitative standards. Assists in the development, implementation and analysis of internal and external benchmarking programs to measure the region's effectiveness in improving performance

• Maintains region-wide Performance Improvement program which includes Customer Satisfaction, complaints, infection monitoring, Incident Reporting, and quarterly branch PI activity

• Provides feedback and recommendations for changes to policies and processes, procedures and systems to enhance measures taken to improve performance

• Communicate with Corporate leadership, Regional and Divisional leaders as appropriate to resolve issues that may place patients or the company at risk

• Oversee educational in-services based on analysis of PI data and activities Acts as a resource for the Operations Support team and communicates Performance Improvement results

• Participate in special projects and performs other duties as assigned.

Use your skills to make an impact

Required Qualifications

• Bachelor's degree in Nursing or related field

• 10-15 years progressively responsible experience in home health or hospice industry that includes performance improvement and outcomes measurement

• 5 years' experience in a supervisory or teaching role

• Thorough knowledge of health care policy, industry and related clinical practice

• Knowledge in the interpretation and application of regulations and performance improvement standards

• Strong Project management principles and clinical policy development/implementation required

• Expert knowledge of all Medicare regulations and appeals processes

• Excellent analytical skills with ability to interpret and apply regulatory requirements

• Excellent verbal/written communication and presentation skills

• Advanced knowledge with 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 organization skills

• Strong attention to detail

• Healthcare industry experience preferred

• Must read, write and speak fluent English

• Must have good and regular attendance

• Approximate percent of time required to travel: 30%

• Performs other related duties as assigned

Preferred Qualifications

• Master's Degree preferred

• Licenses/Certification: RN, PT or OT preferred

• More than 3 years of grievance and appeals experience

• Strong knowledge in Microsoft Access or experience with SQL Server databases

• Previous experience processing medical claims

• Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish

Additional Information

SSN Alert Statement

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from [email protected] with instructions on how to add the information into your official application on Humana's secure website.

Interview Format

As part of our hiring process for this opportunity, we will be using an 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.

WAH Internet Statement

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

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

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

Employees 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 employees 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.

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

Scheduled Weekly Hours

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: 01-30-2026

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 - 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 nation's 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 - 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.

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