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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing complex member complaints and grievances while ensuring compliance with regulatory and policy requirements. Proficient in evaluating high-risk cases and collaborating with cross-functional teams to improve processes and outcomes.
Highest-signal resume keywords
Healthcare Operations ExperienceAppeals And Grievances ManagementRegulatory Compliance KnowledgeDocumentation Standards AdherenceProcess 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 EvaluationRegulatory Requirement InterpretationQuality AssuranceTimeliness ManagementAudit-Ready Documentation
Soft Skills
Effective CommunicationProblem-SolvingCollaborationWorkload PrioritizationGuidance And Mentorship
Industry Keywords
Health Plan SettingCMS RegulationsInsurance OperationsMember ComplaintsGrievances
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
- Determine appropriate resolutions in accordance with 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, audit-ready documentation
- Support escalated, high-visibility, and executive-level complaints
- Assist in drafting responses to regulatory agencies such as CMS and state regulators
- Collaborate with cross-functional stakeholders to resolve cases
- Track regulatory timelines and escalate risks
- Interpret complex 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 standards
- 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 appeals and grievances team within a health plan setting
- Commercial and/or Individual, Family and Business (IFB) plan experience preferred
- Primary home address must be located in a state where Medica is registered as an employer: AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI
- 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- Medical insurance
- Dental insurance
- Vision insurance
- Paid time off (PTO)
- Paid holidays
- Paid volunteer time off
- 401K contributions
- Caregiver services
- Incentive plan compensation may be available in addition to base salary