Clinical Specialist III, Appeals and Grievances

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

📋 Description

• Review, investigate, and resolve appeals and grievances from members and providers that require clinical expertise.

• Conduct clinical assessments of pre-service, concurrent, and post-service cases.

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

• Investigate grievances by analyzing medical records, claims, and accompanying documentation.

• Draft compliant determination letters that adhere to CMS and NCQA regulatory and accreditation standards.

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

• Oversee and support Clinician-to-Clinician (C2C) challenges, including coordination and documentation efforts.

• Monitor appeals and grievances to identify impacts on STARs measures, trends, risks, and opportunities for improvement.

• Partner with quality and operations teams to address trends that influence STARs ratings and enhance member experience.

• Ensure that appeals and C2C activities comply with required turnaround times.

• Maintain precise documentation within case management systems.

• Act as a clinical resource for non-clinical personnel.

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

⛳️ Requirements

• An active, unrestricted RN license is required.

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

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

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

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

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

• Familiarity with STARs measures is preferred.

• Excellent critical thinking and clinical decision-making abilities are necessary.

• Strong written and verbal communication skills are essential.

• Exceptional attention to detail and organizational skills are required.

• Ability to manage multiple priorities while meeting stringent deadlines is necessary.

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

• Primary home address 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, or WI.

• Must be legally authorized to work in the United States.

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

🏝️ Benefits

• Competitive medical, dental, and vision benefits.

• Paid Time Off (PTO).

• Holidays.

• Paid volunteer time off.

• 401K contributions.

• Caregiver services.

• Additional total rewards benefits.