Appeals and Grievances Specialist

Medica•Minnetonka, MN

4d•Hybrid

About The Position

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.

Requirements

Bachelor's degree or equivalent experience in related field
3+ years of work experience beyond degree
3+ years of experience in appeals and grievances, healthcare operations, insurance or related field.
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
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.

Responsibilities

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.
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.
Serve as a primary point of contact for members, patients, providers, and internal departments throughout the grievance and appeals process.
Communicate decisions clearly and professionally while ensuring confidentiality and regulatory compliance.
Provide guidance on appeal rights, procedures, and requirements to stakeholders.
Collaborate with clinical teams, operations, customer service, and other departments to resolve issues and improve member and provider experiences.
Advocate for fair and equitable resolution of disputes while maintaining objectivity and professionalism.
Analyze grievance and appeal trends to identify recurring issues, operational gaps, and opportunities for process improvement.
Develop recommendations and corrective action plans to reduce future disputes and improve service outcomes.
Monitor case closures and maintain the integrity, accuracy, and completeness of grievance and appeals databases.
Support quality improvement initiatives through data analysis, reporting, and stakeholder feedback.