[Hiring] Appeals & Grievances Quality Auditor @Medica

Role Description

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.

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.

Requirements

• 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.

Benefits

• The full salary grade for this position is $56,600 - $97,000.
• The typical hiring salary range for this role is expected to be between $56,600 - $84,840.
• Annual salary range placement will depend on various factors including education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity, and external market salary data.
• 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.

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.

Equal Opportunity Employer

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.