Appeals & Grievances Specialist III

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

📋 Description

• Oversee and resolve intricate member complaints, grievances, appeals, and certain regulatory inquiries.

• Conduct independent reviews and evaluations of complex or high-risk cases.

• Identify suitable resolutions in alignment with regulatory, contractual, clinical, and policy standards.

• Route and coordinate both clinical and non-clinical case elements.

• Communicate conclusions to members, providers, and internal stakeholders.

• Ensure cases adhere to quality, accuracy, timeliness, and compliance benchmarks.

• Maintain comprehensive, precise, and audit-ready documentation.

• Support high-profile, escalated, and executive-level complaints.

• Aid in drafting responses to regulatory bodies such as CMS and state regulators.

• Collaborate with cross-functional teams to resolve cases effectively.

• Monitor regulatory timelines and escalate potential risks.

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

• Identify systemic issues, trends, and gaps in processes.

• Propose and assist in implementing process enhancements.

• Offer guidance to colleagues on complex cases, processes, and documentation practices.

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

• Balance workload amidst competing deadlines and regulatory demands.

• Carry out other responsibilities as assigned.

⛳️ Requirements

• High School Diploma or its equivalent.

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

• At least 1 year of direct experience on a dedicated appeals and grievances team within a healthcare plan setting.

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

• Primary residence must be in a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, 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

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Paid time off (PTO).

• Paid holidays.

• Paid volunteer time off.

• 401K contributions.

• Caregiver services.

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