Appeals and Grievance Specialist

Medica

. Manage and resolve complex member complaints, grievances, appeals, and some regulatory inquiries .

Posted 10/20/2026full-timeRemote • United StatesMid-LevelSenior💰 $45,900 - $68,775 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing complex member complaints and grievances while ensuring compliance with regulatory standards. Proficient in analyzing high-risk cases and collaborating with stakeholders to improve processes and documentation.

Highest-signal resume keywords

3+ Years Experience In Appeals And GrievancesHealthcare OperationsOutstanding Written And Verbal Communication SkillsStrong Problem-Solving And Analytical AbilitiesProficiency With Microsoft Word, Excel, And Outlook

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case ManagementRegulatory ComplianceDocumentation AccuracyProcess ImprovementData Analysis

Soft Skills

Effective CommunicationProblem-SolvingCollaborationTime ManagementAdaptability

Industry Keywords

Member ComplaintsGrievancesRegulatory InquiriesCMSHealthcare Insurance

About the role

Key responsibilities & impact

Manage and resolve complex member complaints, grievances, appeals, and some regulatory inquiries
Independently review and evaluate complex or high-risk cases
Route and coordinate clinical and non-clinical case components
Communicate determinations to members, providers, and internal stakeholders
Ensure cases meet quality, accuracy, timeliness, and compliance standards
Maintain thorough, accurate, and audit-ready documentation
Support escalated, high-visibility, and executive-level complaints
Assist with responses to regulatory agencies such as CMS and state regulators
Collaborate with stakeholders to gather information and resolve cases
Track regulatory timelines and escalate risks
Interpret regulatory requirements, policies, and contractual obligations
Identify systemic issues, trends, and process gaps
Recommend and support process improvements
Provide guidance to peers on complex cases, processes, and documentation
Prioritize workloads across competing deadlines and regulatory requirements

Requirements

What you’ll need

High school diploma or equivalent
3+ years of experience in appeals and grievances, healthcare operations, insurance, or a related field
Outstanding written and verbal communication skills
Strong problem-solving and analytical abilities
Ability to work effectively with staff at all levels, members, and providers
Ability to manage multiple priorities in a fast-paced environment
Proficiency with Microsoft Word, Excel, and Outlook
Primary home address within a state where Medica is registered as an employer: Arkansas, Arizona, Florida, Georgia, Iowa, Illinois, Kansas, Kentucky, Michigan, Minnesota, Missouri, North Dakota, Nebraska, Oklahoma, South Dakota, Tennessee, Texas, Virginia, or Wisconsin
Legally authorized to work in the United States at the time of application
Medica does not offer work visa sponsorship

Benefits

Comp & perks

Competitive medical, dental, and vision benefits
Paid time off (PTO)
Paid holidays
Paid volunteer time off
401(k) contributions
Caregiver services
Incentive plan compensation eligibility
Total rewards package
Remote work arrangement