Regulatory Appeals & Grievances Advisor III

Medica

11d • Remote

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 Regulatory and Appeals Advisor 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, contractual and clinical appeals, executive-level
complaints, provider clinical appeals, and a wide range of regulatory inquiries.

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 experience in the health insurance industry, including at least 1 year specializing in appeals and grievances

Nice To Haves

• Government Programs product experience

Benefits

• competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED