Utilization Review III

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.

The Utilization Review III position is responsible for the review, investigation, and resolution of member and provider appeals and grievances requiring clinical expertise. This role ensures compliance with regulatory requirements, accreditation standards, and organizational policies while promoting quality outcomes, member satisfaction, and STARs performance. The specialist works collaboratively with medical directors, clinical staff, and operational teams to support timely and accurate determinations and oversee clinician-to-clinician (C2C) challenge activities.

Key Responsibilities

• Conduct clinical review of member and provider appeals, including pre-service, concurrent, and post-service cases.

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

• Investigate grievances by reviewing medical records, claims, and related documentation to determine root cause and resolution.

• Prepare clear, concise, and compliant determination letters that meet regulatory and accreditation standards (e.g., CMS, NCQA).

• Collaborate with Medical Directors for cases requiring physician review and support case presentations as needed.

• Oversee and support Clinician-to-Clinician (C2C) challenges, including coordination, documentation, and ensuring timely completion in accordance with regulatory requirements.

• Monitor and assess the impact of appeals and grievances on STARs measures, identifying trends, risks, and opportunities for performance improvement.

• Partner with quality and operations teams to address trends that may negatively impact STARs ratings and member experience.

• Ensure all appeals and C2C activities are processed within required turnaround times.

• Identify trends, quality concerns, and potential process improvement opportunities through case analysis.

• Maintain accurate and complete documentation in case management systems.

• Serve as a clinical resource for non-clinical staff regarding appeals, grievance processes, and clinical escalation pathways.
• Participate in audits, regulatory reporting, and quality improvement initiatives as required.

Education & Experience

• Active, unrestricted clinical license (RN or LPN license required).

• Minimum of 2-3 years of clinical experience (e.g., hospital, utilization management, case management).

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

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

Knowledge, Skills & Abilities

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

• Understanding of regulatory requirements (CMS, Medicare/Medicaid, commercial guidelines, NCQA standards).

• Familiarity with STARs measures and how clinical decisions impact quality performance outcomes.

• Excellent critical thinking and clinical decision-making skills.

• Strong written and verbal communication skills, including the ability to translate clinical information into member-friendly language.

• Exceptional attention to detail and organizational skills.

• Ability to manage multiple priorities and meet strict deadlines.

• Proficiency in case management systems and Microsoft Office applications.

This position is a Remote role.To be eligible for consideration, candidates must have a primary home address located within any 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

The full salary grade for this position is $70,200 - $120,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $70,200 - $105,315. 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 compensation, 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.