Appeals & Grievances Quality Auditor

Medica

Appeals & Grievances Quality Auditor responsible for audits and quality assurance in a nonprofit health plan. Analyzing case compliance and supporting corrective actions for improved member experience.

Posted 7/25/2026full-timeRemote • Arizona, Florida, Illinois, Iowa, Kansas, Kentucky, Minnesota, Missouri, Montana, New York, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Virginia, Wisconsin • 🇺🇸 United StatesMid-LevelSenior💰 $56,600 - $84,840 per yearWebsite

Core Competencies

Role fit

Core Competencies

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

Expertise in conducting audits of Appeals and Grievances cases, ensuring compliance with federal and state regulations, and implementing quality improvement initiatives. Proven ability to provide training and guidance to leadership while maintaining operational controls and quality standards.

Highest-signal resume keywords

Auditing Appeals And GrievancesRegulatory Compliance KnowledgeQuality Improvement InitiativesTraining Development And DeliveryCoaching And Consultation

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

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

Hard Skills

Audit Best PracticesQuality Standards DevelopmentOperational Controls ImplementationCase Quality EvaluationTrends Identification

Soft Skills

CoachingConsultationFeedback Provision

Industry Keywords

Appeals And GrievancesHealth Plan EnvironmentMedicareMedicaidCommercial LinesCMSNCQAAccreditation Standards

About the role

Key responsibilities & impact

Conduct routine and targeted audits of appeals and grievances cases
Ensure adherence to applicable federal and state regulations, accreditation standards, organizational policies, and operational procedures
Evaluate case quality, identify trends and improvement opportunities
Support corrective action initiatives, provide reporting, training, and guidance to appeals and grievances leadership
Participate in quality improvement initiatives focusing on compliance, efficiency, and member experience
Assist with the development and delivery of quality, compliance, and process-related training.

Requirements

What you’ll need

Bachelor's degree or equivalent experience in related field
5 years of work experience beyond degree working directly in Appeals & Grievances within a health plan environment
Background in processing, reviewing, or auditing Appeals and Grievances cases across one or more lines of business (Medicare, Medicaid, or Commercial)
Knowledge of Appeals and Grievances regulatory requirements, including CMS, NCQA, state, and accreditation standards
Ability to develop, implement, and maintain audit best practices, quality standards, and operational controls
Demonstrated success providing coaching, consultation, and quality-related feedback to leaders and operational staff.

Benefits

Comp & perks

competitive medical, dental, vision
PTO
Holidays
paid volunteer time off
401K contributions
caregiver services