Senior Appeals & Grievances Clinician – Remote

Medica; United States; Remote; USD 70,000 - 120,000; Full time

Job summary

Medica is a nonprofit health plan serving members across multiple states. The Appeals and Grievances Clinical Specialist III will review and resolve an array of appeals with clinical input, ensuring regulatory compliance and high STARs performance.

You will collaborate with medical directors and quality teams to address trends, ensure timely determinations, and maintain comprehensive case documentation while supporting clinician-to-clinician challenges.

Qualifications

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

Responsibilities

• Conduct clinical review of member and provider appeals, including pre-service, concurrent, and post-service cases.
• Evaluate medical necessity, appropriateness of care, and benefit coverage using clinical guidelines and evidence-based criteria.
• Investigate grievances by reviewing medical records, claims, and related documentation to determine root cause and resolution.
• Prepare clear, concise, and compliant determination letters that meet regulatory and accreditation standards (e.g., CMS, NCQA).
• Collaborate with Medical Directors for cases requiring physician review and support case presentations as needed.
• Oversee and support Clinician-to-Clinician (C2C) challenges, including coordination, documentation, and ensuring timely completion in accordance with regulatory requirements.
• Monitor and assess the impact of appeals and grievances on STARs measures, identifying trends, risks, and opportunities for performance improvement.
• Partner with quality and operations teams to address trends that may negatively impact STARs ratings and member experience.
• Ensure all appeals and C2C activities are processed within required turnaround times.
• Identify trends, quality concerns, and potential process improvement opportunities through case analysis.
• Maintain accurate and complete documentation in case management systems.
• Serve as a clinical resource for non-clinical staff regarding appeals, grievance processes, and clinical escalation pathways.
• Participate in audits, regulatory reporting, and quality improvement initiatives as required.

Skills

Medical terminology

Clinical guidelines

Regulatory requirements

STARs measures

Critical thinking

Written and verbal communication

Attention to detail

Organizational skills

Multitasking

Microsoft Office

Education

RN license

5+ years clinical experience

Experience in Appeals & Grievances / Utilization Management / Managed Care

Experience with C2C processes & regulatory turnaround requirements & STARs metrics

Tools

Case management systems

Microsoft Office

Job description

Medica is a nonprofit health plan serving members across multiple states. The Appeals and Grievances Clinical Specialist III will review and resolve an array of appeals with clinical input, ensuring regulatory compliance and high STARs performance.

You will collaborate with medical directors and quality teams to address trends, ensure timely determinations, and maintain comprehensive case documentation while supporting clinician-to-clinician challenges.