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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in reviewing and resolving complex member complaints and grievances while ensuring compliance with regulatory and policy requirements. Proficient in collaborating with cross-functional teams and maintaining accurate documentation to support high-quality case management.
Highest-signal resume keywords
Healthcare Operations ExperienceAppeals And Grievances ManagementRegulatory Compliance KnowledgeCMS Guidelines FamiliarityProcess Improvement Recommendations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Case DocumentationRegulatory Requirements InterpretationQuality AssuranceTimeliness MonitoringComplaint Resolution
Soft Skills
Effective CommunicationCollaborationProblem-SolvingWorkload PrioritizationPeer Guidance
Industry Keywords
MedicareMedicaidState Fair HearingHealth Plan SettingInsurance
About the role
Key responsibilities & impact- Independently review and evaluate complex or high-risk member complaints, grievances, and appeals
- Determine appropriate resolutions according to regulatory, contractual, clinical, and policy requirements
- 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 case documentation
- Support escalated, high-visibility, executive-level complaints
- Assist with responses to CMS and state regulatory agencies
- Collaborate with cross-functional stakeholders to resolve cases
- Monitor regulatory timelines and escalate risks
- Interpret regulatory requirements, policies, and contractual obligations
- Identify systemic issues, trends, and process gaps and communicate findings to leadership
- Recommend and support process improvements
- Provide guidance to peers on complex cases, processes, and documentation
- Share casework insights to improve team performance and consistency
- Prioritize workload across competing deadlines and regulatory requirements
- Perform other duties as assigned
Requirements
What you’ll need- High School Diploma or equivalent
- 3+ years of work experience in healthcare operations, insurance, or related field
- 1+ years of direct experience working on a dedicated appeal and grievances team within a health plan setting
- Commercial and/or Individual, Family and Business (IFB) plan experience preferred
- Medicare and/or Medicaid plan experience preferred
- Experience conducting State Fair Hearing preferred
- Experience working with CMS guidelines and/or regulatory agencies preferred
- Ability to work in the Central time zone between core hours of 9 AM - 3 PM CT with start time between 7 AM - 9 AM CT
- Primary home address must be located within a state where Medica is registered as an employer
- Must be legally authorized to work in the United States at the time of application
- Medica does not offer work visa sponsorship for this role
Benefits
Comp & perks- Competitive medical, dental, and vision coverage
- PTO
- Paid holidays
- Paid volunteer time off
- 401K contributions
- Caregiver services
- Incentive plan compensation may be available in addition to base salary