Appeals and Grievance Specialist

Appeals And Grievance Specialist Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. Medica's Appeals and Grievance Specialist plays a vital role in ensuring our members and providers receive clear, timely, and accurate resolutions to their concerns. In this dynamic and impactful position, you will manage and respond to member complaints, grievances appeals, and some regulatory inquiries to ensure accurate, timely, and compliant outcomes. You'll dig into complex case issues, conduct meaningful research, and clearly document your findingsultimately driving fair and compliant case determinations. A key part of your work will include evaluating whether each case is clinical or non-clinical and ensuring it is routed to the appropriate internal partners for successful resolution. This role collaborates closely with teams across Operations, Health Services, Legal, and Markets, creating opportunities to build strong cross-functional relationships and contribute to continuous improvement across the organization. You will help uphold Medica's commitment to regulatory compliance while delivering an exceptional experience for our members and providers. Performs other duties assigned. Required Qualifications: High school diploma or equivalent 3 years of related work experience Preferred Qualifications: 3-5+ years of experience in appeals and grievances, healthcare operations, insurance, or related field Skills and Abilities: Outstanding written and verbal communication skills Strong problem-solving and analytical abilities to ensure timely and thorough case resolution Ability to work effectively with staff at all levels, as well as members and providers Demonstrated skill in managing multiple priorities in a fast-paced environment Proficiency with Microsoft Word, Excel, and Outlook This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, Madison, WI, Omaha, NE or St. Louis, MO. The full salary grade for this position is $45,900 - $78,600. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $45,900 - $68,775. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees. The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law. Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.