Medica

• Provide enterprise leadership to design, standardize, and improve the end to end operating model across HEDIS and Risk Adjustment • Drive improvements in data collection, processing, encounter creation and management, submission controls, reconciliation, and audit readiness • Ensure execution across internal teams, technology partners, analytics, finance, and external vendors is aligned and coordinated • Establish and maintain governance structures for regulatory compliance, audit readiness, and defensible outcomes • Own the end to end vendor operating model for Risk Adjustment • Serve as the primary integrator across Quality, Performance Outcomes, Technology, Data, Analytics, Finance, Actuarial, Provider Quality, and external partners

• Provide member-centered, evidence-based model of care • Understand individual care goals and coordinate care • Assist in finding community resources • Reduce illness burden for individuals and families

• Resolve service inquiries for claims, enrollment, billing, and pharmacy • Explain benefits and interpret contracts • Provide exceptional service satisfaction • Utilize service recovery process for complex situations

• Resolve service inquiries for claims, enrollment, billing, pharmacy • Work telephonically • Provide exceptional levels of service satisfaction • Utilize the service recovery process to assist members in complex situations • Participate in fast-paced and rewarding environment with paid training

Role Description The Utilization Review III position is responsible for the review, investigation, and resolution of member and provider appeals and grievances requiring clinical expertise. This role ensures compliance with regulatory requirements, accreditation standards, and organizational policies while promoting quality outcomes, member satisfaction, and STARs performance. The specialist works collaboratively with medical directors, clinical staff, and operational teams to support timely and accurate determinations and oversee clinician-to-clinician (C2C) challenge activities. - Conduct clinical review of member and provider appeals, including pre-service, concurrent, and post-service cases. - Evaluate medical necessity, appropriateness of care, and benefit coverage using clinical guidelines and evidence-based criteria. - Investigate grievances by reviewing medical records, claims, and related documentation to determine root cause and resolution. - Prepare clear, concise, and compliant determination letters that meet regulatory and accreditation standards (e.g., CMS, NCQA). - Collaborate with Medical Directors for cases requiring physician review and support case presentations as needed. - Oversee and support Clinician-to-Clinician (C2C) challenges, including coordination, documentation, and ensuring timely completion in accordance with regulatory requirements. - Monitor and assess the impact of appeals and grievances on STARs measures, identifying trends, risks, and opportunities for performance improvement. - Partner with quality and operations teams to address trends that may negatively impact STARs ratings and member experience. - Ensure all appeals and C2C activities are processed within required turnaround times. - Identify trends, quality concerns, and potential process improvement opportunities through case analysis. - Maintain accurate and complete documentation in case management systems. - Serve as a clinical resource for non-clinical staff regarding appeals, grievance processes, and clinical escalation pathways. - Participate in audits, regulatory reporting, and quality improvement initiatives as required. Qualifications - Active, unrestricted clinical license (RN or LPN license required). - Minimum of 2–3 years of clinical experience (e.g., hospital, utilization management, case management). - Prior experience in Appeals & Grievances, Utilization Management, or Managed Care strongly preferred. - Experience with C2C processes, regulatory turnaround requirements, and STARs metrics preferred. Requirements - Strong knowledge of medical terminology, clinical guidelines, and healthcare delivery systems. - Understanding of regulatory requirements (CMS, Medicare/Medicaid, commercial guidelines, NCQA standards). - Familiarity with STARs measures and how clinical decisions impact quality performance outcomes. - Excellent critical thinking and clinical decision-making skills. - Strong written and verbal communication skills, including the ability to translate clinical information into member-friendly language. - Exceptional attention to detail and organizational skills. - Ability to manage multiple priorities and meet strict deadlines. - Proficiency in case management systems and Microsoft Office applications. Benefits - Competitive medical, dental, and vision plans. - PTO and Holidays. - Paid volunteer time off. - 401K contributions. - Caregiver services. - Generous total rewards package to support 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.

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 - Coordinating the delivery of services for our members Care Coordinators have the flexibility to choose between working a 4 or 5 day work week, with a consistent schedule free of evenings, weekends, and holidays. They are home-based and reside near the members they support, offering both telephonic and in-home assessments. Key Accountabilities include: - Managing a specified case load of members - Creating individualized care plans and coordinating approved medical and social services - Providing education surrounding benefits including Medicare and Medicaid - Serving as a trusted contact for members to address and mitigate questions or concerns - Partnering with physicians, providers, and county financial entities to discuss care plans - Performing 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 Requirements - 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 Preferred Qualifications - 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 Skills & Abilities - 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 - 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 home office area - General comfort level with technology, with proficiency in the Microsoft Office Suite Compensation & Benefits The full salary grade for this position is $56,600 - $97,000. The typical hiring salary range is expected to be between $56,600 - $84,840, depending on various factors. - Competitive medical, dental, and vision benefits - PTO and Holidays - Paid volunteer time off - 401K contributions - Caregiver services - Many other benefits to support 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. Equal Opportunity Employer We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminately.

• Audits claims for coding accuracy, benefit payment, contract interpretation, and compliance with policies and procedures • Gathers findings at a macro level and makes recommendations for process improvement and efficiencies • Performs professional responsibilities with direct supervision on method and processes • Performs other duties assigned

Role Description Medica's Medical Record Retrieval Specialist collects, reviews, and manages medical records to support clinical reviews, quality programs, and regulatory audits. This role ensures records are obtained accurately, on time, and in compliance with audit and privacy requirements. The specialist works closely with internal clinical and audit teams and external provider offices to resolve documentation gaps, track retrieval status, and maintain audit-ready records. The ideal candidate is organized, detail-oriented, and able to manage multiple priorities. Perform other duties assigned. Key Responsibilities - Record Retrieval & Coordination - Request and retrieve medical records from provider offices, health systems, vendors, and EHR platforms (e.g., Epic, Cerner) using phone, email, fax, portals, and approved systems. - Support HEDIS Hybrid Reviews, CMS Cost Audits, RADV, Data Validation, and other clinical or audit reviews. - Follow established retrieval timelines, protocols, and escalation processes. - Identify and escalate missing, incomplete, or delayed records. - Record Review & Validation - Review records for completeness, legibility, required date ranges, and relevance. - Identify documentation gaps and coordinate follow-ups with providers. - Validate records against audit and project requirements. - Partner with clinical reviewers, auditors, and data teams to clarify documentation needs. - Data Management & Tracking - Upload, index, and organize records in designated systems (e.g., SharePoint, internal audit tools). - Ensure accurate file naming, version control, and proper record association. - Track retrieval status, provider responses, and outstanding requests. - Perform quality checks to ensure records are audit-ready. - Maintain real-time tracking of retrieval status, provider responses, and outstanding requests. - Communication & Compliance - Serve as a point of contact for providers regarding record requests and submissions. - Provide status updates to internal stakeholders. - Document outreach and escalation activities. - Handle PHI in accordance with HIPAA, CMS, and organizational policies. - Use approved secure methods for record transmission and storage. Qualifications - High school diploma or equivalent experience. - 2 years of experience in medical record retrieval, healthcare operations, clinical support, or related field. - Proficiency with Adobe Acrobat and Microsoft Office (Outlook, Excel, SharePoint, Teams). Requirements - Excellent verbal and written communication skills. - Strong organizational, time management, and communication skills. - Ability to manage multiple priorities independently. - Associate degree or higher in Health Information Management or related field. - Experience with HEDIS, CMS Cost Audits, RADV, or other regulatory audits. - Familiarity with EHR systems (e.g., Epic, Cerner) and secure document exchange platforms. - Experience working with provider offices or HIM departments. - Knowledge of healthcare quality measures or regulatory documentation standards. Benefits - Competitive medical, dental, and vision plans. - PTO and Holidays. - Paid volunteer time off. - 401K contributions. - Caregiver services. - Generous total rewards package. Company Description 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.

• Develop and maintain 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 • Manage contract renewals and amendments: Track critical dates, manage the renewal process, and handle amendments as needed • Oversee the entire contract lifecycle: Manage all stages, from initiation and negotiation through execution, monitoring, and closure • Manage provider relations, address issues, and lead dispute resolution processes • Regularly evaluate the performance of assigned networks and providers to identify areas for improvement • Participate in activities related to network adequacy, provider recruitment, and marketing for providers

• Mentor and manage a team of contract managers, guiding them through complex negotiations • Lead and support contract negotiations with providers to secure favorable terms • Oversee the entire contract lifecycle from initiation to execution, monitoring, and renewal/termination • Ensure all contracts comply with federal, state, and industry standards • Analyze contract performance, monitor financial metrics, and recommend improvements • Foster and maintain strategic relationships with provider partners • Develop and maintain policies, procedures, and templates for contracting • Liaise with other departments to ensure accurate implementation of contract terms