Appeals and Grievances Clinical Specialist III

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🔥 44 minutes ago

🌵 Arizona, Florida, +15 more states – Remote

🌵 Arizona – Remote 🐊 Florida – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🌾 Nebraska – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – Remote

💵 $70.2k - $105.3k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Medica

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1975

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Medica is a nonprofit health plan and insurer with over 50 years of experience that provides individual & family plans, Medicare, Medicaid, and employer-provided health plans. It offers member services and tools for finding providers, managing benefits and claims, wellness programs, and community-focused initiatives through the Medica Foundation to advance health equity.

📋 Description

• Conduct clinical review of member and provider appeals, including pre-service, concurrent, and post-service cases • Evaluate medical necessity, appropriateness of care, and benefit coverage using clinical guidelines and evidence-based criteria • Investigate grievances by reviewing medical records, claims, and related documentation to determine root cause and resolution • Prepare clear, concise, and compliant determination letters meeting regulatory and accreditation standards, including CMS and NCQA • Collaborate with Medical Directors on cases requiring physician review and support case presentations as needed • Oversee and support Clinician-to-Clinician (C2C) challenges, including coordination, documentation, and timely completion • Monitor and assess the impact of appeals and grievances on STARs measures, identifying trends, risks, and performance improvement opportunities • Partner with quality and operations teams to address trends negatively impacting STARs ratings and member experience • Ensure appeals and C2C activities are processed within required turnaround times • Identify trends, quality concerns, and process improvement opportunities through case analysis • Maintain accurate and complete documentation in case management systems • Serve as a clinical resource for non-clinical staff regarding appeals, grievance processes, and clinical escalation pathways • Participate in audits, regulatory reporting, and quality improvement initiatives

🎯 Requirements

• Active, unrestricted RN license required • 5+ years of clinical experience • Prior experience in Appeals & Grievances, Utilization Management, or Managed Care strongly preferred • Experience with C2C processes, regulatory turnaround requirements, and STARs metrics preferred • Strong knowledge of medical terminology, clinical guidelines, and healthcare delivery systems • Understanding of CMS, Medicare/Medicaid, commercial guidelines, and NCQA standards • Familiarity with STARs measures and clinical impacts on quality performance outcomes • Excellent critical thinking and clinical decision-making skills • Strong written and verbal communication skills, including translating clinical information into member-friendly language • Exceptional attention to detail and organizational skills • Ability to manage multiple priorities and meet strict deadlines • Proficiency in case management systems and Microsoft Office applications • Primary home address must be located in AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, or WI • Must be legally authorized to work in the United States at the time of application • Medica does not offer work visa sponsorship for this role

🏖️ Benefits

• Competitive medical insurance • Dental insurance • Vision insurance • PTO • Holidays • Paid volunteer time off • 401K contributions • Caregiver services • Many other benefits to support employees