Appeals & Grievances Quality Auditor

About Medica

Medica is a nonprofit health plan serving over a million members across Minnesota, Nebraska, Wisconsin, Missouri, and beyond. The organization focuses on delivering personalized health care experiences and works closely with providers to ensure members receive genuine, quality care. The team values accountability, data-driven decision making, continuous learning, and collaborative success to create a community of connected care where every member feels appreciated.

Role Overview

The Appeals & Grievances Quality Auditor performs both routine and focused reviews of appeals and grievances cases, ensuring compliance with federal and state regulations, accreditation standards, organizational guidelines, and internal procedures. This position assesses case quality, detects patterns and improvement areas, aids in corrective action efforts, and offers reports, training, and guidance to leadership.

The auditor contributes to regulatory compliance readiness, quality enhancement projects, staff education, and ongoing monitoring efforts to improve compliance, operational efficiency, and the member experience. Ideal candidates have strong analytical and problem-solving abilities and must be knowledgeable about health plan appeals and grievances processes along with pertinent healthcare regulatory requirements.

Key Responsibilities

• Conduct comprehensive audits of appeals and grievances cases to verify adherence to regulatory, accreditation, and organizational mandates.
• Review documentation, case determinations, correspondence, timeliness, and procedural accuracy.
• Ensure compliance with turnaround times, notification protocols, and documentation standards.
• Analyze audit findings to identify trends, root causes, compliance risks, and opportunities for improvements.
• Generate and distribute audit reports, dashboards, scorecards, and quality performance metrics.
• Monitor key quality indicators and provide recommendations to leadership for better results and risk mitigation.
• Collaborate with leaders to resolve audit findings and establish corrective action plans.
• Engage in quality improvement initiatives aiming at compliance, operational efficiency, and enhanced member experience.
• Suggest improvements to workflows, policies, training materials, and job aids.
• Support internal audit preparations, regulatory reviews, and accreditation surveys.
• Offer coaching and feedback to leadership regarding audit outcomes and quality standards.
• Help develop and deliver training related to quality, compliance, and process improvements.
• Serve as a resource for appeals and grievances quality standards, regulations, and best practices.
• Participate in special projects and other departmental activities as assigned.

Qualifications

• Bachelor's degree or equivalent experience in a related field.
• At least 5 years of professional experience working directly in Appeals & Grievances within a health plan setting.

Preferred Experience

• Experience in processing, reviewing, or auditing Appeals and Grievances cases across Medicare, Medicaid, and Commercial lines of business.
• Familiarity with regulatory requirements including CMS, NCQA, state, and accreditation standards.
• Involvement in process improvement focused on regulatory compliance, operational efficiency, and member satisfaction.
• Capability to establish and maintain audit best practices, quality benchmarks, and operational controls.
• Proven ability to provide coaching and consultation on quality and compliance matters to both leaders and staff.

Additional Information

This role is fully remote; candidates must reside in a state where Medica is a registered employer (AR, AZ, FL, GA, IA, IL, KS, KY, MI, MN, MO, ND, NE, OK, SD, TN, TX, VA, WI).

Salary range: $56,600 to $97,000 annually, with typical hiring between $56,600 and $84,840 depending on background and experience. Compensation is supplemented by a comprehensive benefits package that includes medical, dental, vision coverage, paid time off, holidays, volunteer time off, 401K contributions, caregiver services, and other employee supports. Salary and benefits may be subject to change.

Internal candidates must have completed at least one year in their current position to apply.

Candidates must be legally authorized to work in the U.S. Medica does not provide work visa sponsorship for this position.

Medica is an Equal Opportunity Employer, committed to nondiscriminatory hiring practices regarding race, religion, ethnicity, nationality, citizenship, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.