Appeals & Grievance Advisor

Medica's Appeals & Grievance Advisor manages and responds to member and provider complaints, appeals, and regulatory inquiries. This role ensures compliance with state and federal regulations while partnering with internal teams to drive cases to resolution. Performs other duties as assigned.

Key Accountabilities

• Manages and responds to member complaints, grievances, contractual appeals, clinical appeals, executive level complaints, and regulatory inquiries.
• Partner with Operations, Health Services, Legal, and Markets teams to resolve cases.
• Determine case type (clinical or non-clinical) for appropriate internal review.
• Research and document case details and final determinations.
• Perform other duties as assigned.

The successful candidate will demonstrate strong analytical and communication skills, work effectively across departments, and maintain a high level of accuracy and professionalism in handling sensitive member and provider issues.

Qualifications

• Bachelor's degree or equivalent combination of education and related work experience
• 3+ years of health insurance industry experience

Strongly Preferred Qualifications

• Demonstrated proficiency in HealthRules and/or ISET required
• Government Programs product experience

Skills and Abilities

• Excellent written and verbal communication
• Problem solving and analytical skills for timely and thorough problem resolution
• Works well with all levels of staff, members, and providers
• Ability to manage multiple priorities
• Proficient in Microsoft applications - Word, Excel, and Outlook

This position is an Office role, which requires an employee to work onsite at our Minnetonka, MN or Madison, WI office, on average, 3 days per week.

The full salary range for this position is $44,900-$77,000. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.