Remote Senior Clinical Appeals & Grievances Specialist

Medica; Minnetonka (MN); Remote; USD 70,000 - 120,000; Full time

Job summary

Medica is a nonprofit health plan serving diverse communities with a mission to provide coordinated, quality care. The Appeals and Grievances Clinical Specialist III role focuses on reviewing, investigating, and resolving member and provider appeals with clinical expertise, ensuring regulatory compliance and quality outcomes.

You will collaborate with Medical Directors, clinical staff, and operations to support timely determinations, oversee C2C challenges, and contribute to STARs performance

Qualifications

• Active, unrestricted RN license required.
• 5+ years of clinical experience.
• Prior experience in Appeals & Grievances, Utilization Management, or Managed Care preferred.
• Experience with C2C processes, regulatory turnaround requirements, and STARs metrics preferred.

Responsibilities

• Review member and provider appeals, including pre-service, concurrent, and post-service cases.
• Investigate grievances by reviewing records and resolving root causes.
• Prepare clear determinations meeting CMS/NCQA standards.
• Coordinate with Medical Directors for physician reviews as needed.
• Support C2C challenges and ensure timely completion per regulations.
• Monitor STARs impact and identify improvement opportunities.

Skills

RN license

5+ years clinical experience

CMS/NCQA knowledge

Regulatory turnaround knowledge

Education

Active RN license

Tools

Case management systems

Microsoft Office

Job description

Medica is a nonprofit health plan serving diverse communities with a mission to provide coordinated, quality care. The Appeals and Grievances Clinical Specialist III role focuses on reviewing, investigating, and resolving member and provider appeals with clinical expertise, ensuring regulatory compliance and quality outcomes.

You will collaborate with Medical Directors, clinical staff, and operations to support timely determinations, oversee C2C challenges, and contribute to STARs performance