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[Remote] Regulatory and Appeals Advisor
Note: The job is a remote job and is open to candidates in USA. Medica is a nonprofit health plan serving over a million members across various states, committed to delivering personalized healthcare experiences. The Regulatory and Appeals Advisor will manage member complaints, grievances, and regulatory inquiries while ensuring compliance and fostering collaboration across teams.
Responsibilities
- Manage and respond to member complaints, grievances, contractual and clinical appeals, executive-level complaints, provider clinical appeals, and a wide range of regulatory inquiries
- Dig into complex case issues, conduct meaningful research, and clearly document findings
- Evaluate whether each case is clinical or non-clinical and ensure it is routed to the appropriate internal partners for successful resolution
- Collaborate closely with teams across Operations, Health Services, Legal, and Markets to build strong cross-functional relationships and contribute to continuous improvement across the organization
- Uphold Medica’s commitment to regulatory compliance while delivering an exceptional experience for members and providers
- Perform other duties as assigned
Skills
- High school diploma or equivalent
- 3+ years of related work experience
- 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
- Government Programs product experience
Benefits
- Competitive medical
- Dental
- Vision
- PTO
- Holidays
- Paid volunteer time off
- 401K contributions
- Caregiver services
- Many other benefits to support our employees
Company Overview
