Appeals and Grievances Manager

Medica•St. Louis, MO

4h•Hybrid

About The Position

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 Grievances Manager supports the day‑to‑day operations of the Appeals and Grievances team, ensuring work is completed accurately, on time, and in compliance with regulatory requirements. This role keeps the team running smoothly by supporting supervisors, handling escalated or highly visible issues, and assisting with audits, reporting, and process improvements. This role is critical to ensuring the Appeals and Grievances team operates effectively and consistently, allowing leadership to focus on strategy while maintaining high service and regulatory standards. Performs other duties assigned.

Requirements

Associate’s degree or equivalent combination of education and experience
5+ years of related professional experience
Prior leadership experience in claims, enrollment, billing, or customer service
Strong operational and organizational skills
Ability to manage complex, regulated work in a fast‑paced environment
Comfortable handling escalated and sensitive issues
Clear communicator who can work across teams and leadership levels
Ability to lead through change and identify process improvement

Nice To Haves

Experience in health insurance, managed care, appeals and grievances, regulatory compliance, or a related field
Familiarity with CMS, NCQA, and state regulatory requirements

Responsibilities

Oversee daily department operations to ensure cases are handled timely and accurately
Provide leadership, guidance, and support to supervisors, including one‑on‑ones and team meetings
Ensure compliance with applicable regulatory and accreditation requirements (CMS, NCQA, and state regulations)
Assist with audits and regulatory reviews, including reporting and documentation preparation
Monitor grievance and appeal trends and identify improvement opportunities
Support supervisors and staff with escalated, complex, or high‑visibility cases
Partner with regulatory, clinical, and cross‑functional teams to resolve issues and improve processes
Drive consistency, accountability, and effective execution across the team