Claim Appeals & Correspondence II

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 Claim Appeals & Correspondence II position is responsible for managing assigned inventory related to claim appeals, customer service concerns, internal inquiries, and escalated VIP issues. This intermediate-level role supports post-adjudication claims operations by researching, analyzing, and resolving claim processing issues with limited supervision. The position works collaboratively with cross-functional partners to resolve claim decisions and questions while supporting accurate and timely outcomes. Performs other duties as assigned.

Key Responsibilities

• Manage daily inventory of claim appeals, customer service issues, internal inquiries, and escalated VIP cases
• Research, analyze, and resolve claim processing issues and questions
• Review claims to identify processing discrepancies and determine appropriate next steps
• Manage assigned reports, work baskets, correspondence, email assignments, and special projects through completion
• Collaborate with PNOM, 1st Pass Claims, PI, Coding, Configuration, and other departments as needed to resolve claim decisions and questions
• Independently manage moderately complex administrative responsibilities with limited supervision
• Provide timely responses and updates regarding open claims, inquiries, and escalated cases
• Maintain effective working relationships with internal business partners
• Meet established quality, productivity, and inventory management expectations
• Support process improvement efforts that promote claims accuracy and operational efficiency

Required Qualifications

• High school diploma or equivalent
• 2 years of related work experience

Preferred Qualifications

• Experience in health insurance, healthcare administration, or claims operations
• Experience researching, adjusting, or reprocessing medical claims
• Knowledge of Medicare and Medicaid programs
• Understanding of Coordination of Benefits (COB)
• Experience managing high-volume inventories, queues, work baskets, or case management systems
• Knowledge of commercial and government healthcare claims
• Experience working collaboratively across claims-related operational functions

Skills and Abilities

• Strong analytical and problem-solving skills with the ability to research and resolve moderately complex issues
• Ability to work independently with limited supervision
• Basic proficiency in Microsoft Excel, including sorting, filtering, and working with spreadsheets
• Strong verbal and written communication skills
• Strong customer service and relationship-building skills
• Ability to manage multiple priorities and assigned inventory in a fast-paced environment
• Strong attention to detail and accuracy
• Ability to collaborate effectively across departments

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 $37,600 - $64,400. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $37,600 - $56,385. 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.

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.