Supv, Appeals & Grievances
Molina Healthcare Albany, New York; Everett, Washington; New Mexico; Nebraska; Jacksonville, Florida; New York, New York; Covington, Kentucky; Green Bay, Wisconsin; Atlanta, Georgia; Detroit, Michigan; Seattle, Washington; Tampa, Florida; Orem, Utah; Cleveland, Ohio; Grand Rapids, Michigan; Buffalo, New York; Ohio; Utah; San Antonio, Texas; Spokane, Washington; Kearney, Nebraska; Rochester, New York; Yonkers, New York; Warren, Michigan; Santa Fe, New Mexico; Albuquerque, New Mexico; Syracuse, New York; Iowa; Wisconsin; West Valley City, Utah; Savannah, Georgia; Columbus, Georgia; Tucson, Arizona; Roswell, New Mexico; Cedar Rapids, Iowa; Augusta, Georgia; Mesa, Arizona; Fort Worth, Texas; Meridian, Idaho; Kentucky; Ann Arbor, Michigan; Milwaukee, Wisconsin; Miami, Florida; Bellevue, Nebraska; Caldwell, Idaho; Columbus, Ohio; Sterling Heights, Michigan; Dallas, Texas; Phoenix, Arizona; Salt Lake City, Utah; Georgia; Iowa City, Iowa; Texas; Dayton, Ohio; Idaho Falls, Idaho; Orlando, Florida; Owensboro, Kentucky; Boise, Idaho; Tacoma, Washington; St. Petersburg, Florida; Grand Island, Nebraska; Austin, Texas; Madison, Wisconsin; Las Cruces, New Mexico; Racine, Wisconsin; Idaho; Michigan; Provo, Utah; Scottsdale, Arizona; Florida; Nampa, Idaho; Des Moines, Iowa; New York; Washington; Davenport, Iowa; Layton, Utah; Bowling Green, Kentucky; Macon, Georgia; Lincoln, Nebraska; Houston, Texas; Kenosha, Wisconsin; Cincinnati, Ohio; Louisville, Kentucky; Lexington-Fayette, Kentucky; Omaha, Nebraska; Akron, Ohio; Vancouver, Washington; Sioux City, Iowa; Bellevue, Washington; Chandler, Arizona; Rio Rancho, New Mexico Job ID 2031510JOB DESCRIPTION
Job Summary
Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member and provider complaints and communicating resolution to provider and members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid
KNOWLEDGE/SKILLS/ABILITIES
- Supervises staff responsible for the submission/resolution of member and provider inquiries or grievances. Ensures resolutions are compliant.
- Assesses and audits business processes to determine those most effective and efficient at resolving member and provider problems.
- Interfaces with corporate counterparts and member services and ensures standard processes are implemented.
- Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits, and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.
- Maintains call tracking system and database of correspondence and outcomes for provider and member appeals; monitors each appeal to ensure all internal and regulatory timelines are met.
JOB QUALIFICATIONS
REQUIRED EDUCATION:
Bachelor's degree or equivalent experience
REQUIRED EXPERIENCE:
- 5Â years experience in claims review and member and provider appeal resolution.
- Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
- Previous experience leading projects or lead experience
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $77,969 - $116,835 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
About Us
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full Time Posting Date: 05/12/2025ABOUT OUR LOCATION
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