Appeals & Grievances Quality Auditor

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

The Appeals & Grievances Quality Auditor is responsible for conducting routine and targeted audits of appeals and grievances cases, ensuring adherence to applicable federal and state regulations, accreditation standards, organizational policies, and operational procedures. This role evaluates case quality, identifies trends and improvement opportunities, supports corrective action initiatives, and provides reporting, training, and guidance to appeals and grievances leadership. The role supports regulatory readiness, quality improvement initiatives, staff training, and ongoing monitoring activities designed to strengthen compliance, operational effectiveness, and member experience. The ideal candidate possesses strong analytical, auditing, and problem-solving skills, along with a solid understanding of health plan appeals and grievances processes and healthcare regulatory requirements.

Key Accountabilities

Quality Auditing & Compliance

• Conduct routine and targeted audits of appeals and grievances cases to evaluate compliance with regulatory, accreditation, and organizational requirements.
• Review case documentation, determinations, correspondence, timeliness, and procedural accuracy.
• Monitor compliance with established turnaround times, notification requirements, and documentation standards.

Reporting & Analysis

• Analyze audit results to identify trends, root causes, compliance risks, and opportunities for improvement.
• Prepare and distribute audit reports, dashboards, scorecards, and quality metrics.
• Track quality performance indicators and provide recommendations to improve outcomes and reduce risk to leadership.
• Support the development of monitoring plans and quality assurance strategies.

Quality Improvement

• Partner with leadership to address audit findings and implement corrective action plans.
• Participate in quality improvement initiatives focused on compliance, efficiency, and member experience.
• Recommend enhancements to workflows, policies, procedures, training materials, and job aids.
• Support readiness activities for internal audits, regulatory reviews, and accreditation surveys.

Training & Consultation

• Provide coaching and feedback to leadership regarding audit results and quality expectations.
• Assist with the development and delivery of quality, compliance, and process-related training.
• Serve as a resource on appeals and grievances quality standards, regulatory requirements, and best practices.
• Participate in special projects and other departmental initiatives as assigned.

Required Qualifications

• 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

Preferred Qualifications

• Background in processing, reviewing, or auditing Appeals and Grievances cases across one or more lines of business (Medicare, Medicaid, and Commercial).
• Knowledge of Appeals and Grievances regulatory requirements, including CMS, NCQA, state, and accreditation standards.
• Participation in process improvement initiatives focused on operational efficiency, regulatory compliance, and member experience.
• 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.

This position is a Remote role.To be eligible for consideration, candidates must have a primary home address located within any 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, WI.

The full salary grade for this position is $56,600 - $97,000. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $56,600 - $84,840. 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.

Internal Applicants: We're excited about your interest in growing your career at Medica! To be eligible to apply for internal opportunities, employees must have been in their current role for at least one year.

Recruiter: Stacey Manley

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

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.