Appeals and Grievance Specialist

About the role

The Medica Appeals and Grievance Specialist plays a vital role in ensuring our members and providers receive clear, timely, and accurate resolutions to their concerns. This role involves managing and responding to member complaints, grievances, and some regulatory inquiries.

Responsibilities

• Manage and respond to member complaints, grievances, and some regulatory inquiries to ensure accurate, timely, and compliant outcomes.
• Dig into complex case issues, conduct meaningful research, and clearly document findings to drive fair and compliant case determinations.
• Evaluate whether each case is clinical or non-clinical and ensure it is routed to the appropriate internal partners for successful resolution.
• Collaborate closely with teams across Operations, Health Services, Legal, and Markets to build strong cross-functional relationships and contribute to continuous improvement.
• Help uphold Medica’s commitment to regulatory compliance while delivering an exceptional experience for our members and providers.
• Perform other duties assigned.

Requirements

• High school diploma or equivalent
• 3 years of related work experience

Preferred Qualifications

• 3-5+ years of experience in appeals and grievances, healthcare operations, insurance, or related field

Skills And Abilities

• Outstanding written and verbal communication skills
• Strong problem-solving and analytical abilities to ensure timely and thorough case resolution
• Ability to work effectively with staff at all levels, as well as members and providers
• Demonstrated skill in managing multiple priorities in a fast-paced environment
• Proficiency with Microsoft Word, Excel, and Outlook

Pay

The full salary grade for this position is $45,900 - $78,600. The typical hiring salary range for this role is expected to be between $45,900 - $68,775. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data.

Benefits

Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services, and many other benefits to support our employees.

Schedule

This position is an Office role, requiring an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, Omaha, NE, or St. Louis, MO.