Appeals & Grievances Quality Auditor

🔥 3 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

💵 $56.6k - $84.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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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 routine and targeted audits of appeals and grievances cases • Ensure adherence to applicable federal and state regulations, accreditation standards, organizational policies, and operational procedures • Evaluate case quality, identify trends and improvement opportunities • Support corrective action initiatives, provide reporting, training, and guidance to appeals and grievances leadership • Participate in quality improvement initiatives focusing on compliance, efficiency, and member experience • Assist with the development and delivery of quality, compliance, and process-related training.

🎯 Requirements

• Bachelor's degree or equivalent experience in related field • 5 years of work experience beyond degree working directly in Appeals & Grievances within a health plan environment • Background in processing, reviewing, or auditing Appeals and Grievances cases across one or more lines of business (Medicare, Medicaid, or Commercial) • Knowledge of Appeals and Grievances regulatory requirements, including CMS, NCQA, state, and accreditation standards • Ability to develop, implement, and maintain audit best practices, quality standards, and operational controls • Demonstrated success providing coaching, consultation, and quality-related feedback to leaders and operational staff.

🏖️ Benefits

• competitive medical, dental, vision • PTO • Holidays • paid volunteer time off • 401K contributions • caregiver services