Appeals and Grievances Specialist

JOB REQUIREMENTS: Description 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 Appeals & Grievances Specialist plays a vital role in ensuring fair, timely, and compliant resolution of member and provider disputes. This position helps maintain trust, improve customer satisfaction, and uphold organizational integrity by balancing empathy, objectivity, and regulatory compliance when resolving complex issues. The specialist serves as a key liaison between stakeholders and the organization, helping drive continuous improvement in service quality and operational effectiveness. Manages and responds to member complaints, grievances, contractual appeals, clinical appeals, executive level complaints, and regulatory inquiries. Performs other duties as assigned. Key Accountabilities Case Management and Resolution Receive, review, and process grievances and appeals from members, patients, providers, or clients regarding claims, coverage, benefits, and service concerns. Conduct thorough investigations to gather relevant information, assess the validity of complaints, and determine appropriate resolutions. Manage pre-service authorizations, concurrent and retrospective medical necessity reviews, and complex provider claim disputes. Ensure timely and accurate processing of appeals and grievances in accordance with established policies and regulatory requirements. Maintain complete and accurate documentation of all complaints, investigations, decisions, and resolutions within organizational systems. Regulatory Compliance and Reporting Ensure all grievance and appeal activities comply with applicable federal, state, and organizational regulations, including CMS, DHCS, DMHC, NCQA, and other governing standards. Prepare reports and summaries for leadership and regulatory agencies as required, identifying trends, root causes, and potential areas of concern. Participate in internal audits, external reviews, inter-rater reliability assessments, and compliance oversight activities. Monitor performance metrics and case turnaround times to ensure compliance with regulatory and contractual requirements. Stakeholder Communication and Support Serve as a primary point of contact for members, patients, providers, and internal departments... For full info follow application link. Equal Opportunity Employer including Veterans and Disabled Individuals ***** APPLICATION INSTRUCTIONS: Apply Online: ipc.us/t/44C577431A36497F