Appeals and Grievances Clinical Specialist III

This is a fully remote position, open to applicants in Arizona, +16 more states.

📋 Description

• Perform clinical evaluations of member and provider appeals, encompassing pre-service, concurrent, and post-service cases.

• Assess medical necessity, appropriateness of care, and benefit coverage in accordance with clinical guidelines and evidence-based criteria.

• Review medical records, claims, and related documentation to investigate grievances, determining root causes and resolutions.

• Draft clear, concise, and compliant determination letters that adhere to regulatory and accreditation standards, such as CMS and NCQA.

• Collaborate with Medical Directors on cases that necessitate physician review and assist with case presentations as required.

• Manage and facilitate Clinician-to-Clinician (C2C) challenges, ensuring proper coordination, documentation, and timely completion.

• Monitor and evaluate the influence of appeals and grievances on STARs measures, identifying trends, risks, and opportunities for performance enhancement.

• Work in partnership with quality and operations teams to address trends that adversely affect STARs ratings and member experience.

• Ensure that appeals and C2C activities are processed within established turnaround times.

• Identify trends, quality issues, and opportunities for process improvements through case analysis.

• Maintain precise and comprehensive documentation in case management systems.

• Act as a clinical resource for non-clinical staff regarding appeals, grievance procedures, and clinical escalation pathways.

• Engage in audits, regulatory reporting, and quality improvement initiatives.

⛳️ Requirements

• Must possess an active, unrestricted RN license.

• A minimum of 5 years of clinical experience is required.

• Previous experience in Appeals & Grievances, Utilization Management, or Managed Care is strongly preferred.

• Familiarity with C2C processes, regulatory turnaround requirements, and STARs metrics is preferred.

• Strong understanding of medical terminology, clinical guidelines, and healthcare delivery systems.

• Knowledge of CMS, Medicare/Medicaid, commercial guidelines, and NCQA standards is essential.

• Awareness of STARs measures and their clinical impact on quality performance outcomes.

• Excellent critical thinking and clinical decision-making abilities.

• Strong written and verbal communication skills, including the ability to translate clinical information into language accessible to members.

• Exceptional attention to detail and organizational abilities.

• Capability to manage multiple priorities and adhere to strict deadlines.

• Proficiency in case management systems and Microsoft Office applications is required.

• Candidates must reside in one of the following states: 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 provide work visa sponsorship for this position.

🏝️ Benefits

• Competitive medical insurance.

• Dental insurance.

• Vision insurance.

• Paid time off (PTO).

• Holidays.

• Paid volunteer time off.

• 401K contributions.

• Caregiver services.

• Numerous other benefits designed to support employees.