Specialist, Appeals & Grievances
Molina Healthcare New York, New York; Seattle, Washington; Albuquerque, New Mexico; Des Moines, Iowa; Sterling Heights, Michigan; Grand Island, Nebraska; Kearney, Nebraska; Santa Fe, New Mexico; Buffalo, New York; San Antonio, Texas; Dallas, Texas; West Valley City, Utah; Washington; Vancouver, Washington; Spokane, Washington; Tucson, Arizona; Augusta, Georgia; Macon, Georgia; Georgia; Iowa City, Iowa; Idaho Falls, Idaho; Nebraska; Roswell, New Mexico; Albany, New York; Dayton, Ohio; Orem, Utah; Madison, Wisconsin; Orlando, Florida; Davenport, Iowa; Boise, Idaho; Idaho; Grand Rapids, Michigan; Bellevue, Nebraska; Omaha, Nebraska; Las Cruces, New Mexico; Akron, Ohio; Cincinnati, Ohio; Wisconsin; Racine, Wisconsin; Chandler, Arizona; Bowling Green, Kentucky; Owensboro, Kentucky; Fort Worth, Texas; Salt Lake City, Utah; Provo, Utah; Green Bay, Wisconsin; Florida; Sioux City, Iowa; Michigan; Ann Arbor, Michigan; Rio Rancho, New Mexico; New York; Milwaukee, Wisconsin; Phoenix, Arizona; Mesa, Arizona; Scottsdale, Arizona; Tampa, Florida; Miami, Florida; Columbus, Georgia; Atlanta, Georgia; Meridian, Idaho; Covington, Kentucky; Warren, Michigan; Detroit, Michigan; Austin, Texas; Texas; Layton, Utah; Utah; St. Petersburg, Florida; Iowa; Nampa, Idaho; Louisville, Kentucky; Lincoln, Nebraska; Yonkers, New York; Rochester, New York; Columbus, Ohio; Ohio; Cleveland, Ohio; Houston, Texas; Tacoma, Washington; Kenosha, Wisconsin; Savannah, Georgia; Cedar Rapids, Iowa; Caldwell, Idaho; Kentucky; Lexington-Fayette, Kentucky; New Mexico; Syracuse, New York; Everett, Washington; Bellevue, Washington; Jacksonville, Florida Job ID 2031076JOB DESCRIPTION
Job Summary
Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid
KNOWLEDGE/SKILLS/ABILITIES
- Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.
- Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.Â
- Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines.
- Responsible for meeting production standards set by the department.
- Apply contract language, benefits, and review of covered services
- Responsible for contacting the member/provider through written and verbal communication.
- Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
- Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
- Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
- Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies
JOB QUALIFICATIONS
REQUIRED EDUCATION:
High School Diploma or equivalency
REQUIRED EXPERIENCE:
- Min. 2 years operational managed care experience (call center, appeals or claims environment).
- Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.
- Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
- Strong verbal and written communication skills
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: $21.16 - $38.37 / HOURLY
*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: 04/07/2025ABOUT OUR LOCATION
View Map- Specialist, Pharmacy Ops Albany New York, Everett Washington, Utah, Florida, Idaho, Wisconsin, Texas, Georgia, Michigan, New Mexico, Kentucky, Washington, Iowa, Nebraska, New York, Ohio, New York New York, Orem Utah, Vancouver Washington, Spokane Washington, Cincinnati Ohio, Savannah Georgia, Madison Wisconsin, Phoenix Arizona, Chandler Arizona, Rio Rancho New Mexico, Covington Kentucky, Lincoln Nebraska, Grand Island Nebraska, Provo Utah, Nampa Idaho, Houston Texas, Des Moines Iowa, Akron Ohio, Bellevue Washington, Tacoma Washington, Seattle Washington, Syracuse New York, Buffalo New York, Augusta Georgia, Caldwell Idaho, Tucson Arizona, Fort Worth Texas, Dayton Ohio, Cleveland Ohio, West Valley City Utah, Grand Rapids Michigan, Sterling Heights Michigan, Rochester New York, Racine Wisconsin, Milwaukee Wisconsin, Boise Idaho, Meridian Idaho, Austin Texas, Owensboro Kentucky, Louisville Kentucky, Omaha Nebraska, Layton Utah, Jacksonville Florida, Orlando Florida, Columbus Ohio, Kenosha Wisconsin, Idaho Falls Idaho, Albuquerque New Mexico, Las Cruces New Mexico, Kearney Nebraska, Iowa City Iowa, Roswell New Mexico, Ann Arbor Michigan, Yonkers New York, Columbus Georgia, Mesa Arizona, Dallas Texas, Bowling Green Kentucky, Bellevue Nebraska, Sioux City Iowa, Davenport Iowa, Cedar Rapids Iowa, Salt Lake City Utah, Detroit Michigan, Tampa Florida, Miami Florida, Macon Georgia, Green Bay Wisconsin, Scottsdale Arizona, Warren Michigan, St. Petersburg Florida, Atlanta Georgia, San Antonio Texas, Santa Fe New Mexico, Lexington-Fayette Kentucky 04/11/2025
- Engineer, Big Data - Databricks/Python/SQL/Power BI - Remote Albany New York, Everett Washington, Georgia, Iowa City Iowa, Caldwell Idaho, Covington Kentucky, Louisville Kentucky, Omaha Nebraska, Lincoln Nebraska, Las Cruces New Mexico, Ohio, Orem Utah, Kenosha Wisconsin, Tucson Arizona, Tampa Florida, Sioux City Iowa, Cedar Rapids Iowa, Nampa Idaho, Kentucky, Grand Island Nebraska, New Mexico, New York New York, New York, Cleveland Ohio, Austin Texas, Miami Florida, Jacksonville Florida, Atlanta Georgia, Macon Georgia, Columbus Georgia, Savannah Georgia, Davenport Iowa, Idaho Falls Idaho, Meridian Idaho, Boise Idaho, Grand Rapids Michigan, Santa Fe New Mexico, Dallas Texas, Salt Lake City Utah, Spokane Washington, Tacoma Washington, Madison Wisconsin, Scottsdale Arizona, Augusta Georgia, Warren Michigan, Nebraska, Fort Worth Texas, Seattle Washington, Racine Wisconsin, Phoenix Arizona, Orlando Florida, Bowling Green Kentucky, Detroit Michigan, Sterling Heights Michigan, Kearney Nebraska, Buffalo New York, Rochester New York, Cincinnati Ohio, Houston Texas, Texas, Utah, Layton Utah, Florida, Iowa, Michigan, Albuquerque New Mexico, Akron Ohio, San Antonio Texas, West Valley City Utah, Washington, Idaho, Wisconsin, St. Petersburg Florida, Des Moines Iowa, Owensboro Kentucky, Ann Arbor Michigan, Syracuse New York, Mesa Arizona, Chandler Arizona, Lexington-Fayette Kentucky, Bellevue Nebraska, Rio Rancho New Mexico, Roswell New Mexico, Yonkers New York, Dayton Ohio, Columbus Ohio, Provo Utah, Vancouver Washington, Bellevue Washington, Green Bay Wisconsin, Milwaukee Wisconsin 03/31/2025
- Rep, MTM Pharmacy Services I Everett Washington, Albany New York, Boise Idaho, Kentucky, Owensboro Kentucky, Covington Kentucky, Michigan, Warren Michigan, Omaha Nebraska, Dallas Texas, Augusta Georgia, Iowa City Iowa, Cedar Rapids Iowa, Meridian Idaho, Lexington-Fayette Kentucky, Nebraska, Rio Rancho New Mexico, Rochester New York, Dayton Ohio, New York New York, Chandler Arizona, Tampa Florida, Georgia, Ohio, Columbus Ohio, Texas, Salt Lake City Utah, Spokane Washington, Wisconsin, Racine Wisconsin, Caldwell Idaho, Louisville Kentucky, Grand Island Nebraska, Las Cruces New Mexico, New Mexico, Akron Ohio, San Antonio Texas, Washington, Madison Wisconsin, Green Bay Wisconsin, Idaho, Bellevue Nebraska, Roswell New Mexico, Cleveland Ohio, Austin Texas, Provo Utah, Utah, Layton Utah, Orem Utah, Vancouver Washington, Tacoma Washington, Kenosha Wisconsin, Tucson Arizona, Florida, Macon Georgia, Idaho Falls Idaho, Ann Arbor Michigan, Santa Fe New Mexico, Cincinnati Ohio, Fort Worth Texas, Houston Texas, West Valley City Utah, Bellevue Washington, Milwaukee Wisconsin, St. Petersburg Florida, Savannah Georgia, Columbus Georgia, Des Moines Iowa, Iowa, Davenport Iowa, Bowling Green Kentucky, Detroit Michigan, Sterling Heights Michigan, Grand Rapids Michigan, Kearney Nebraska, Albuquerque New Mexico, Scottsdale Arizona, Mesa Arizona, Jacksonville Florida, Miami Florida, Nampa Idaho, Lincoln Nebraska, New York, Syracuse New York, Yonkers New York, Buffalo New York, Seattle Washington, Phoenix Arizona, Orlando Florida, Atlanta Georgia, Sioux City Iowa 03/20/2025
- Business Analyst, Tech Config Info Mgmt Albany New York, Everett Washington, Jacksonville Florida, Tampa Florida, Augusta Georgia, Atlanta Georgia, Ohio, Kenosha Wisconsin, Kearney Nebraska, Albuquerque New Mexico, Des Moines Iowa, Meridian Idaho, Miami Florida, St. Petersburg Florida, Orlando Florida, Rio Rancho New Mexico, Santa Fe New Mexico, West Valley City Utah, Layton Utah, Buffalo New York, Tacoma Washington, Cincinnati Ohio, Idaho, Boise Idaho, Grand Rapids Michigan, Ann Arbor Michigan, Iowa City Iowa, Austin Texas, Nebraska, New Mexico, Provo Utah, Seattle Washington, Cleveland Ohio, Nampa Idaho, Owensboro Kentucky, Mesa Arizona, Kentucky, Warren Michigan, Chandler Arizona, Phoenix Arizona, Georgia, Dayton Ohio, Milwaukee Wisconsin, Roswell New Mexico, Syracuse New York, New York New York, Vancouver Washington, Akron Ohio, Bowling Green Kentucky, Sioux City Iowa, Dallas Texas, Green Bay Wisconsin, Racine Wisconsin, Omaha Nebraska, Bellevue Nebraska, Yonkers New York, Rochester New York, Louisville Kentucky, Florida, Savannah Georgia, Cedar Rapids Iowa, Fort Worth Texas, Texas, Madison Wisconsin, Las Cruces New Mexico, Bellevue Washington, Spokane Washington, New York, Iowa, Caldwell Idaho, Idaho Falls Idaho, Lexington-Fayette Kentucky, Sterling Heights Michigan, Michigan, Tucson Arizona, Columbus Georgia, Davenport Iowa, Wisconsin, Lincoln Nebraska, San Antonio Texas, Salt Lake City Utah, Orem Utah, Washington, Covington Kentucky, Detroit Michigan, Scottsdale Arizona, Macon Georgia, Houston Texas, Grand Island Nebraska, Utah, Columbus Ohio 04/11/2025
No recently viewed jobs.
View All JobsNo saved jobs.
View All Jobs