Appeals and Grievances Specialist

🔥 0 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

💵 $45.9k - $68.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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

• Receive, review, and process grievances and appeals from members, patients, providers, or clients regarding claims, coverage, benefits, and service concerns. • Conduct thorough investigations to gather relevant information, assess the validity of complaints, and determine appropriate resolutions. • Manage pre-service authorizations, concurrent and retrospective medical necessity reviews, and complex provider claim disputes. • Ensure timely and accurate processing of appeals and grievances in accordance with established policies and regulatory requirements. • Maintain complete and accurate documentation of all complaints, investigations, decisions, and resolutions within organizational systems. • Ensure all grievance and appeal activities comply with applicable federal, state, and organizational regulations. • Prepare reports and summaries for leadership and regulatory agencies as required, identifying trends, root causes, and potential areas of concern. • Analyze grievance and appeal trends to identify recurring issues, operational gaps, and opportunities for process improvement.

🎯 Requirements

• Bachelor's degree or equivalent experience in related field • 3+ years of work experience beyond degree • 3+ years of experience in appeals and grievances, healthcare operations, insurance or related field. • 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.

🏖️ Benefits

• Medical • Dental • Vision • PTO • Holidays • Paid volunteer time off • 401K contributions • Caregiver services