Medica

• Receive, review, and process grievances and appeals from members, patients, providers, or clients regarding claims, coverage, benefits, and service concerns. • Conduct thorough investigations to gather relevant information, assess the validity of complaints, and determine appropriate resolutions. • Manage pre-service authorizations, concurrent and retrospective medical necessity reviews, and complex provider claim disputes. • Ensure timely and accurate processing of appeals and grievances in accordance with established policies and regulatory requirements. • Maintain complete and accurate documentation of all complaints, investigations, decisions, and resolutions within organizational systems. • Ensure all grievance and appeal activities comply with applicable federal, state, and organizational regulations. • Prepare reports and summaries for leadership and regulatory agencies as required, identifying trends, root causes, and potential areas of concern. • Analyze grievance and appeal trends to identify recurring issues, operational gaps, and opportunities for process improvement.

Role Description Medica’s Care Coordinators work across the state of Minnesota, integrated in communities to support and care for senior members and members living with disabilities. Our Care Coordinators are passionate about collaboratively aligning resources, creating appropriate individualized care plans, and coordinating the delivery of services for our members. - Work independently to manage a specified case load of members. - Create appropriate individualized care plans and coordinate the delivery of approved medical and social services. - Provide education surrounding benefits including Medicare and Medicaid. - Serve as a trusted and primary contact for members to address and mitigate questions or concerns. - Partner with physicians, providers, and county financial entities to discuss care plans and provide updates on member progress. - Perform other duties as assigned. Qualifications - Bachelor’s degree in Social Work. - 3+ years of experience beyond degree, including 1-2+ years of community-based services. - Active, unrestricted SW License in the state of MN required. - MnCHOICES Certified Assessor Training (MNCAT) preferred or ability to obtain within 21 days of employment. - Public Health Certification preferred, however not required. Requirements - Experience in home and community-based services/case management. - Experience working with those who have a disability and with seniors. - Comfortable working with diverse, low-income populations. - Strong knowledge of Medicare and Medical Assistance programs. - Excellent interpersonal skills with the ability to simplify medical language for non-medically trained members. - Ability to shift gears quickly, function independently, and reprioritize tasks to meet needs of members and the Medica Care System. - Strong clinical and documentation skills. - Strong innovative problem-solving ability. - Exceptional organizational skills with the ability to work independently. - Willingness to travel within Medica's Service Area. - Reliable transportation and a designated private area for home office environment. - General comfort level with technology, with proficiency in the Microsoft Office Suite. Benefits - Competitive medical, dental, and vision insurance. - PTO and holidays. - Paid volunteer time off. - 401K contributions. - Caregiver services. - Mileage reimbursement for travel to member homes. 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.

• Develop and maintain ACO provider networks yielding a competitive, geographic, stable network that achieves objectives for unit cost performance and trend management. • Produces an affordable and predictable network for customers and business partners. • Evaluates and negotiates contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls. • Establishes and maintains strong business relationships with Hospital, Physician, Pharmacy, or Ancillary providers, and ensures the network composition includes an appropriate distribution of provider specialties. • Performs other duties as assigned. • Negotiate and draft contracts: Negotiate terms with providers, ensuring they align with Medica's financial goals and standard template agreements. • Manage contract renewals and amendments: Track critical dates, manage the renewal process, and handle amendments as needed. • Maintain contracts: Keep contractual language and fee schedules up-to-date with current medical policy changes and reimbursement structures. • Oversee the entire contract lifecycle: Manage all stages, from initiation and negotiation through execution, monitoring, and closure. • Build and maintain relationships: Develop and nurture strong relationships with providers, including high-level representatives of key contracting entities. • Resolve issues: Manage provider relations, address issues, and lead dispute resolution processes. • Conduct performance assessments: Regularly evaluate the performance of assigned networks and providers to identify areas for improvement. • Support network growth: Participate in activities related to network adequacy, provider recruitment, and marketing for providers.

• leads day-to-day clinical review and medical record operations supporting complex, time-sensitive regulatory audits and quality initiatives • provides direct supervision, coaching, and workload management for Clinical Quality Review RNs • ensures audit deliverables, documentation standards, and regulatory timelines are met • exercises independent judgment, proactively identifies operational risks, resolves escalations, and adapts workflows in response to changing audit requirements, data availability, and business priorities • assists Manager with supporting an efficient department operation and workflow • works with other departments to assure workflow is adequate to meet the needs of the project/audit • coaches staff through complex, ambiguous, or high-risk audit scenarios • identifies and assists in resolution of escalated and/or complex issues • supports daily operations and long-range planning for the department • collaborates with department and all business segments to ensure that consistent, effective and timely communication occurs • assists with data collection and audits • develops and/or assist with training and training materials • works with HR to recruit and hire new staff • supports staff resilience and performance during peak audit periods • balances productivity expectations with quality and compliance standards

• Apply Medical Coding Standards to Claims & Clinical Documentation • Review and code clinical documentation using ICD, CPT, HCPCS, and internal coding guidelines. • Validate coding accuracy to support compliant billing, reimbursement, and data reporting. • Research missing or unclear information to ensure proper code assignment. • Complete timely coding reviews that enable accurate claims processing. • Conduct Coding Reviews & Identify Discrepancies • Perform audits of claims, encounters, and documentation to detect coding errors or inconsistencies. • Analyze coding patterns to identify trends, risks, or gaps affecting payment accuracy. • Document findings clearly and recommend corrective actions that reduce recurrence. • Communicate audit results to internal partners, ensuring clarity, professionalism, and follow-through. • Troubleshoot Coding-Related Issues Across Operational Processes • Investigate coding impacts on claims adjudication, reimbursement, and provider disputes. • Collaborate with configuration, operations, and provider teams to resolve issues efficiently. • Verify coding rules within system logic and flag discrepancies for correction. • Support issue triage workflows that improve operational stability and payment accuracy. • Support Coding Quality, Compliance, & Documentation Standards • Apply coding regulations, payer guidelines, and organizational policies consistently. • Maintain compliance with regulatory requirements, audit standards, and documentation expectations. • Participate in coding quality initiatives that strengthen accuracy and reduce rework. • Monitor updates to coding rules and support implementation of required changes. • Serve as a Knowledge Resource & Contribute to Team Objectives • Provide guidance to junior analysts on coding practices, documentation requirements, and audit methods. • Assist with training, documentation updates, and knowledge‑sharing within the team. • Participate in process improvement efforts that enhance coding workflows and accuracy. • Contribute to team goals by delivering reliable expertise, consistent quality, and timely work. • Other duties as assigned.

Role Description Medica’s Engagement Coordinators work to engage and triage members to align them with appropriate care support programs. They are accountable for telephonic member outreach, triage and steerage, driving targeted engagement and participation. The Engagement Coordinators conduct primarily outbound calls to identified members, utilizing a structured assessment process/protocol. However, the Engagement Coordinator will need to be confident in their ability to make real-time (non-clinical) screening as to the most appropriate intervention for identified members. Member follow-up may be warranted, but on a limited basis. This is a great opportunity to make a difference in our members’ lives. It is important that our Engagement Coordinators understand, articulate and support the organization’s mission, vision, goals and strategies while maintaining confidentiality of all privileged information. Ideal candidates promote a high level of customer service to both external and internal customers and are highly effective at phone work and retaining program knowledge across Medica’s continuum of Care Management programs. - Conduct proactive outbound outreach to health plan members to introduce and promote case management programs, averaging approximately 40 outbound calls per day - Educate members on the benefits and value of case management services, helping them understand available resources and support options - Assess member needs through meaningful conversations, identifying gaps in care and determining eligibility or appropriateness for case management enrollment - Build rapport and establish trust with members through active listening, empathy, and effective communication techniques - Successfully engage and enroll eligible members into case management programs by understanding individual health and support needs - Support administrative functions such as reporting, inbox management, tracking outreach activities, and maintaining program records - Collaborate closely with case managers, care coordination teams, and internal stakeholders to ensure seamless member engagement and support - Perform other duties as assigned Qualifications - High School diploma, equivalent combination of education and work experience - 2+ years’ experience in a member-facing telephonic engagement or related experience Requirements - Experience in a customer service, call center, managed care or health care related corporate environments preferred - Self-starter, independent functioning with strong organizational, service and communication skills - Experience collaborating with providers and other health professionals preferred - Strong communications, service and people skills including empathy and non-judgmental approach with emphasis on conciseness and ability to decipher undertones and unspoken messages Skills & Abilities - Demonstrated autonomy, initiative in handling work, strong analytical and problem-solving skills to proactively assess project needs and barriers and initiate solutions - Advanced computer skills and application knowledge specifically Microsoft Office applications. Has intuitive ability to pick up new computer programs easily - Ability to effectively facilitate phone conversations to assess and engage people in programs - Attention to detail and accuracy a must; excellent organizational skills - Excellent written, verbal, and interpersonal skills with all levels of employees and management - Ability to seamlessly adjust projects based on department priorities and to manage multiple projects at one time - Multi-tasking: listen, facilitate conversation and behavior change while documenting and navigating through the system - Utilize programs related to recruitment as required: workflow, eligibility, claims, Microsoft Office software (Word, Excel, Access, etc.) and others as appropriate - Effectively manage phone, including accuracy of login/logout and use of aux modes - Be proficient in the use of quality monitoring system to review monthly audits Remote Work Eligibility 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. Compensation The full salary grade for this position is $41,300 - $70,800. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $41,300 - $61,950. 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. 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.

• 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.

• Provide a member-centric, evidence-based model of care across multiple products • Serve the members with highest needs and help them navigate the health system • Conduct individualized assessments to identify each member’s goals of care • Coordinate services across various settings • Connect members with community resources that align with their needs • Collaborate with members and their families, caregivers, providers, and interdisciplinary teams

• Provide member-centered, evidence-based model of care across multiple products • Serve maternal members with the highest needs and help them navigate the health system • Focus on improving maternal and infant health outcomes • Deliver education, care coordination, identify gaps in care, and advocacy • Reduce the risk of pregnancy and birth-related complications for individuals and their families while decreasing healthcare costs • Perform other duties as assigned.

• Provide member-centered, evidence-based model of care across multiple products • Ensure smooth and safe transition for members between various care settings • Assess individual care goals and coordinate medical and supportive services • Connect members with community resources to support their needs and objectives