Appeals and Grievance Specialist

Medica•Minnetonka, MN

1d•Hybrid

About The Position

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 findings—ultimately 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.

Requirements

High school diploma or equivalent
3 years of related work experience
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
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.

Nice To Haves

3-5+ years of experience in appeals and grievances, healthcare operations, insurance, or related field

Responsibilities

Manage and respond to member complaints, grievances appeals, and some regulatory inquiries to ensure accurate, timely, and compliant outcomes.
Evaluate whether each case is clinical or non-clinical and ensuring it is routed to the appropriate internal partners for successful resolution.
Collaborate closely with teams across Operations, Health Services, Legal, and Markets.
Uphold Medica’s commitment to regulatory compliance while delivering an exceptional experience for our members and providers.
Performs other duties assigned.