Remote Senior Appeals & Grievances Specialist

Medica; Minnesota; Hybrid; USD 46,000 - 79,000; Full time

Job summary

Medica is a nonprofit health plan actively serving communities in Minnesota and beyond. The Appeals & Grievances Specialist III role manages and resolves member complaints, grievances, and regulatory inquiries with advanced judgment and independent work.

The position emphasizes compliance, audit readiness, and cross-functional collaboration. This remote role requires US work eligibility and offers a competitive salary with comprehensive benefits.

Qualifications

• 3+ years of work experience in healthcare operations.
• 1+ years of direct experience on a dedicated appeals and grievances team within a health plan setting.

Responsibilities

• Independently review and resolve complex or high-risk member complaints, grievances, and appeals in line with regulatory, contractual, clinical, and policy requirements.
• Support escalations and regulatory inquiries, including drafting compliant responses to CMS and state regulators.
• Apply advanced regulatory and administrative expertise to guide case handling and drive process improvements.
• Collaborate with internal teams to resolve issues and ensure consistent workflows and audit readiness.
• Prioritize workload and exercise sound judgment to influence outcomes while maintaining compliance.

Skills

Healthcare operations

Appeals & grievances

Education

High School Diploma or equivalent

Job description

Medica is a nonprofit health plan actively serving communities in Minnesota and beyond. The Appeals & Grievances Specialist III role manages and resolves member complaints, grievances, and regulatory inquiries with advanced judgment and independent work.

The position emphasizes compliance, audit readiness, and cross-functional collaboration. This remote role requires US work eligibility and offers a competitive salary with comprehensive benefits.