Clinical Specialist III, Appeals and Grievances

Medica

. Review, investigate, and resolve member and provider appeals and grievances requiring clinical expertise .

Posted 10/14/2026full-timeRemote • United StatesMid-LevelSenior💰 $70,200 - $120,400 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive clinical expertise in Appeals and Grievances, Utilization Management, and Managed Care, with a strong focus on regulatory compliance and quality improvement initiatives. Proficient in evaluating medical necessity and preparing compliant determination letters in accordance with CMS and NCQA standards.

Highest-signal resume keywords

Active RN License5+ Years Clinical ExperienceAppeals & Grievances ExpertiseKnowledge of CMS and NCQA StandardsProficiency in Case Management Systems

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewMedical Necessity EvaluationEvidence-Based Criteria ApplicationDocumentation PreparationC2C Process ManagementRegulatory ReportingQuality Improvement InitiativesSTARs Metrics UnderstandingMicrosoft Office ProficiencyAttention to Detail

Soft Skills

Critical ThinkingClinical Decision-MakingWritten CommunicationVerbal CommunicationOrganizational Skills

Tools & Technologies

Case Management SystemsMicrosoft Office Applications

Certifications & Qualifications

Active RN License

Industry Keywords

Managed CareUtilization ManagementCMS StandardsMedicareMedicaidNCQA StandardsHealthcare Delivery SystemsSTARs Measures

About the role

Key responsibilities & impact

Review, investigate, and resolve member and provider appeals and grievances requiring clinical expertise
Conduct clinical review of 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
Prepare compliant determination letters meeting CMS and NCQA regulatory and accreditation standards
Collaborate with Medical Directors on cases requiring physician review and support case presentations
Oversee and support Clinician-to-Clinician (C2C) challenges, including coordination and documentation
Monitor appeals and grievances for impacts on STARs measures, trends, risks, and improvement opportunities
Partner with quality and operations teams to address trends affecting STARs ratings and member experience
Ensure appeals and C2C activities meet required turnaround times
Maintain accurate documentation in case management systems
Serve as a clinical resource for non-clinical staff
Participate in audits, regulatory reporting, and quality improvement initiatives

Requirements

What you’ll need

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
Strong knowledge of medical terminology, clinical guidelines, and healthcare delivery systems
Understanding of CMS, Medicare/Medicaid, commercial guidelines, and NCQA standards
Familiarity with STARs measures
Excellent critical thinking and clinical decision-making skills
Strong written and verbal communication skills
Exceptional attention to detail and organizational skills
Ability to manage multiple priorities and meet strict deadlines
Proficiency in case management systems and Microsoft Office applications
Primary home address 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, or WI
Legally authorized to work in the United States
Medica does not offer work visa sponsorship for this role

Benefits

Comp & perks

Competitive medical, dental, and vision benefits
PTO
Holidays
Paid volunteer time off
401K contributions
Caregiver services
Other total rewards benefits