Appeals and Grievances Specialist

Medica

Appeals & Grievances Specialist at Medica ensuring fair, timely resolution of member and provider disputes in healthcare. Supports quality improvement and regulatory compliance within the organization.

Posted 7/29/2026full-timeRemote • Arizona, Florida, Illinois, Iowa, Kansas, Kentucky, Minnesota, Missouri, Montana, New York, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Virginia, Wisconsin • 🇺🇸 United StatesMid-LevelSenior💰 $45,900 - $68,775 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in managing grievances and appeals within healthcare operations, ensuring compliance with regulatory requirements while effectively analyzing trends and improving processes. Proficient in documentation and communication to facilitate timely resolutions and reporting.

Highest-signal resume keywords

Grievance And Appeal ManagementHealthcare OperationsRegulatory ComplianceAnalytical Problem-SolvingMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Grievance ProcessingAppeal ProcessingMedical Necessity ReviewDocumentation ManagementData Analysis

Soft Skills

Outstanding Communication SkillsProblem-Solving AbilitiesAbility To Manage Multiple Priorities

Tools & Technologies

Microsoft WordMicrosoft ExcelMicrosoft Outlook

Industry Keywords

Claims ManagementHealthcare CompliancePatient AdvocacyInsurance Operations

About the role

Key responsibilities & impact

Receive, review, and process grievances and appeals from members, patients, providers, or clients regarding claims, coverage, benefits, and service concerns.
Conduct thorough investigations to gather relevant information, assess the validity of complaints, and determine appropriate resolutions.
Manage pre-service authorizations, concurrent and retrospective medical necessity reviews, and complex provider claim disputes.
Ensure timely and accurate processing of appeals and grievances in accordance with established policies and regulatory requirements.
Maintain complete and accurate documentation of all complaints, investigations, decisions, and resolutions within organizational systems.
Ensure all grievance and appeal activities comply with applicable federal, state, and organizational regulations.
Prepare reports and summaries for leadership and regulatory agencies as required, identifying trends, root causes, and potential areas of concern.
Analyze grievance and appeal trends to identify recurring issues, operational gaps, and opportunities for process improvement.

Requirements

What you’ll need

Bachelor's degree or equivalent experience in related field
3+ years of work experience beyond degree
3+ years of experience in appeals and grievances, healthcare operations, insurance or related field.
Outstanding written and verbal communication skills
Strong problem-solving and analytical abilities to ensure timely and thorough case resolution
Ability to work effectively with staff at all levels, as well as members and providers
Demonstrated skill in managing multiple priorities in a fast-paced environment
Proficiency with Microsoft Word, Excel, and Outlook.

Benefits

Comp & perks

Medical
Dental
Vision
PTO
Holidays
Paid volunteer time off
401K contributions
Caregiver services