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Director, Appeals & Grievances (Medicare / Provider Claims) - REMOTE
Molina Healthcare Florida; Everett, Washington; Bellevue, Washington; Owensboro, Kentucky; West Valley City, Utah; Cleveland, Ohio; Idaho; Kearney, Nebraska; Cincinnati, Ohio; Columbus, Georgia; Tucson, Arizona; Sioux City, Iowa; Nampa, Idaho; Ann Arbor, Michigan; Racine, Wisconsin; Syracuse, New York; Atlanta, Georgia; Yonkers, New York; Provo, Utah; Washington; Des Moines, Iowa; Columbus, Ohio; Boise, Idaho; Lincoln, Nebraska; Tacoma, Washington; Orem, Utah; Santa Fe, New Mexico; Grand Rapids, Michigan; Buffalo, New York; Cedar Rapids, Iowa; Idaho Falls, Idaho; Chandler, Arizona; Milwaukee, Wisconsin; Scottsdale, Arizona; Fort Worth, Texas; Albany, New York; Savannah, Georgia; St. Petersburg, Florida; Dayton, Ohio; San Antonio, Texas; Madison, Wisconsin; Salt Lake City, Utah; Kentucky; Texas; Louisville, Kentucky; Bellevue, Nebraska; Akron, Ohio; Jacksonville, Florida; Albuquerque, New Mexico; Las Cruces, New Mexico; Lexington-Fayette, Kentucky; Warren, Michigan; Georgia; Ohio; New York; Michigan; Utah; Layton, Utah; Augusta, Georgia; Dallas, Texas; Orlando, Florida; Detroit, Michigan; Tampa, Florida; Kenosha, Wisconsin; Wisconsin; New Mexico; Roswell, New Mexico; Rio Rancho, New Mexico; Spokane, Washington; Caldwell, Idaho; Covington, Kentucky; Omaha, Nebraska; Davenport, Iowa; Iowa City, Iowa; Phoenix, Arizona; Rochester, New York; Sterling Heights, Michigan; Meridian, Idaho; Grand Island, Nebraska; Macon, Georgia; Houston, Texas; Iowa; Austin, Texas; Green Bay, Wisconsin; Bowling Green, Kentucky; Miami, Florida; Mesa, Arizona; Vancouver, Washington; Nebraska Job ID 2032218Job Summary
Responsible for leading, organizing and directing the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.
Knowledge/Skills/Abilities
• Leads, organizes, and directs the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes that is responsible for reviewing and resolving contracted provider disputes for 20+ states.
• Provides direct oversight, monitoring and training of Contracted Provider disputes and appeals to ensure adherence with Molina claims processing standards and provider contractual agreements. Includes responsibility from start to finish of the claim disputes to include intake, processing, decisioning, adjusting, and responding timely to claim disputes. Team consists of clinical and non-clinical staff.
• Establishes Medicare Contracted Provider Post Pay dispute and appeals policies/procedures and updates annually or as directed otherwise.
• Collaborates with Health Plan leaders to ensure Contracted Provider appeals and disputes are processed in accordance with local Health Plan requirements
• Works with Claims, Configuration, Contracting, Provider Data Management, and other business partners to resolve provider concerns related to their claim’s dispositions.
• Provides robust root cause analysis identifying top drivers and works with Health Plans and other business partners to improve and reduce claim related appeals and disputes.
• Supports activities surrounding material updates including provider manuals, letters, and other correspondence related to Medicare Contracted Provider Appeals and Disputes.
• Responsible for meeting all departmental key performance indicators (KPI’s) with multiple targets depending on Medicare Program and State requirements.
Job Qualifications
Required Education
Associate's degree or 4 years of Medicare Claim Experience.
Required Experience
• 7 years' experience in healthcare claims review and/or Provider appeals and grievance processing/resolution, including 2 years in a manager role.
• Experience reviewing all types of medical claims (e.g. CMS 1500, Outpatient/Inpatient, Universal Claims, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing), and IPA.
- 2 years supervisory/management experience with appeals/grievance and/or claims processing within a managed care setting.
Preferred Education
Bachelor's degree
Previous Director 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: $97,299 - $189,679 / 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 07/16/2025Job Alerts
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