Appeals and Grievances Intake Lead

Medica•Madison, WI

2d•$45,900 - $68,775•Hybrid

About The Position

The Intake Lead provides advanced operational leadership and subject matter expertise in the intake, triage, and assignment of member complaints, grievances, appeals, and regulatory inquiries. This role ensures accurate, timely, and compliant intake processes while managing high-risk and high-volume workflows. Operating with a high degree of autonomy, the Intake Lead drives consistency, quality, and efficiency across intake operations, strengthens regulatory readiness, and supports enterprise service and compliance objectives.

Requirements

HS diploma or equivalent
4+ years of work experience beyond degree serving as a lead or SME in appeals and grievances intake or case management functions
Eligibility to work in the US

Responsibilities

Direct the intake and triage of complex, sensitive, and high-priority cases, ensuring accurate classification and routing.
Ensure all incoming cases meet regulatory, contractual, and internal documentation requirements at initiation.
Monitor intake volumes, queue management, and SLA adherence; proactively address bottlenecks and workflow gaps.
Maintain strong controls to ensure cases are audit-ready from intake through resolution.
Oversee intake of executive-level complaints, regulatory inquiries, and escalations to ensure urgency and accuracy.
Validate completeness and quality of submissions to support compliant downstream handling and decision-making.
Coordinate with cross-functional partners (e.g., Pharmacy, Clinical, Operations, Vendors) to obtain missing or critical information.
Ensure regulatory timelines are triggered accurately and consistently at intake.
Serve as the primary SME for intake policies, classification standards, and regulatory requirements.
Interpret evolving regulatory and contractual guidance to ensure appropriate case intake and categorization.
Identify intake-related trends, risks, and root causes; recommend and implement process improvements.
Lead updates to SOPs and intake guidelines to drive standardization and operational excellence.
Monitor intake performance metrics, including volume, turnaround times, accuracy, and backlog.
Support ad hoc reporting, trend analysis, and action planning for leadership.
Partner with A&G leadership to improve upstream processes and enhance end-to-end case flow.
Drive initiatives that improve intake efficiency, quality, and overall member experience.
Provides day-to-day work guidance and operational support to promote effective, consistent, and compliant execution of assigned tasks, without direct supervisory responsibility.
Provides direction and clarification on assigned work to support understanding of priorities, expectations, timelines, and established standards.
Uses practical knowledge of processes, policies, and procedures to support accurate task execution and to identify issues requiring escalation.
Coordinates assigned work activities and routine communication to promote consistency, surface dependencies, and address basic issues impacting quality or timelines.
Reviews work for completeness, accuracy, and adherence to documented guidelines, escalating concerns or exceptions as appropriate.
Shares status updates, risks, and observations with appropriate partners or leaders to support awareness and timely resolution of issues.