Appeals & Grievances Specialist

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

📋 Description

• Conduct thorough reviews and evaluations of complex or high-risk member complaints, grievances, and appeals independently.

• Identify suitable resolutions in accordance with regulatory, contractual, clinical, and policy guidelines.

• Coordinate and route both clinical and non-clinical components of cases.

• Communicate decisions effectively to members, providers, and internal stakeholders.

• Ensure that all cases adhere to standards of quality, accuracy, timeliness, and compliance.

• Maintain detailed, accurate, and audit-ready documentation for all cases.

• Assist with escalated, high-visibility complaints at the executive level.

• Support the preparation of responses to CMS and state regulatory agencies.

• Collaborate with stakeholders across various functions to resolve cases efficiently.

• Track regulatory timelines and escalate any potential risks appropriately.

• Interpret regulatory requirements, policies, and contractual obligations accurately.

• Identify systemic issues, trends, and process gaps while communicating findings to leadership.

• Propose and support improvements to processes.

• Provide mentorship to peers on intricate cases, processes, and documentation practices.

• Share insights from casework to enhance team performance and consistency.

• Manage workload effectively amidst competing deadlines and regulatory obligations.

• Perform additional duties as assigned.

⛳️ Requirements

• High School Diploma or equivalent is required.

• Minimum of 3 years of experience in healthcare operations, insurance, or a related field.

• At least 1 year of direct experience on an appeals and grievances team within a health plan environment.

• Experience with Commercial and/or Individual, Family and Business (IFB) plans is preferred.

• Background in Medicare and/or Medicaid plans is preferred.

• Familiarity with conducting State Fair Hearings is preferred.

• Experience working with CMS guidelines and/or regulatory agencies is preferred.

• Ability to operate within the Central time zone during core hours of 9 AM - 3 PM CT, with a start time between 7 AM - 9 AM CT.

• Primary residence must be located in a state where Medica is registered as an employer.

• Must be legally authorized to work in the United States at the time of application.

• Please note that Medica does not provide work visa sponsorship for this position.

🏝️ Benefits

• Competitive medical, dental, and vision insurance.

• Paid time off (PTO).

• Paid holidays.

• Paid volunteer time off.

• 401K contributions.

• Access to caregiver services.

• Incentive plan compensation may be available in addition to the base salary.