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 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 complaints and communicating resolution to members or authorized representatives 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 Appeals & Grievances unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with Centers for Medicare and Medicaid standards/requirements.
• Provides direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements related to non-contracted provider dispute/appeals processing.
• Establishes member and non-contracted provider grievance/dispute and appeals policies/procedures and updates annually or as directed by the Centers for Medicare and Medicaid Services.
• Trains grievance and appeals staff, customer/member services department, sales, UM and other departments within Molina Medicare and Medicaid on early recognition and timely routing of member complaints.
• Trains each state's provider dispute resolution unit on CMS standards and requirements, including the proper use of the Molina Provider Grievance and appeals system.
• Reviews and analyzes collective grievance and appeals data along with audit results on unit's performance; analyzes and interprets trends and prepares reports that identify root causes of member dissatisfaction; recommends and implements process improvements to achieve member/provider satisfaction or operational effectiveness/efficiencies which contribute to Molina Medicare's maximum STAR ratings.
Job Qualifications
Required Education
Associate's degree or 4 years of Medicare grievance and appeals 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 processing within a managed care setting.
Preferred Education
Bachelor's degree.
Previous Director experience.
IPA support 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: 07/16/2025ABOUT OUR LOCATION
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