Appeals & Grievances Specialist

🔥 2 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

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Independently review and evaluate complex or high-risk member complaints, grievances, and appeals • Determine appropriate resolutions according to regulatory, contractual, clinical, and policy requirements • Route and coordinate clinical and non-clinical case components • Communicate determinations to members, providers, and internal stakeholders • Ensure cases meet quality, accuracy, timeliness, and compliance standards • Maintain thorough, accurate, and audit-ready case documentation • Support escalated, high-visibility, executive-level complaints • Assist with responses to CMS and state regulatory agencies • Collaborate with cross-functional stakeholders to resolve cases • Monitor regulatory timelines and escalate risks • Interpret regulatory requirements, policies, and contractual obligations • Identify systemic issues, trends, and process gaps and communicate findings to leadership • Recommend and support process improvements • Provide guidance to peers on complex cases, processes, and documentation • Share casework insights to improve team performance and consistency • Prioritize workload across competing deadlines and regulatory requirements • Perform other duties as assigned

🎯 Requirements

• High School Diploma or equivalent • 3+ years of work experience in healthcare operations, insurance, or related field • 1+ years of direct experience working on a dedicated appeal and grievances team within a health plan setting • Commercial and/or Individual, Family and Business (IFB) plan experience preferred • Medicare and/or Medicaid plan experience preferred • Experience conducting State Fair Hearing preferred • Experience working with CMS guidelines and/or regulatory agencies preferred • Ability to work in the Central time zone between core hours of 9 AM - 3 PM CT with start time between 7 AM - 9 AM CT • Primary home address must be located within a state where Medica is registered as an employer • 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, dental, and vision coverage • PTO • Paid holidays • Paid volunteer time off • 401K contributions • Caregiver services • Incentive plan compensation may be available in addition to base salary