Specialist, Appeals & Grievances
Molina Healthcare Michigan; Provo, Utah; Scottsdale, Arizona; Spokane, Washington; Albany, New York; Bellevue, Nebraska; Bowling Green, Kentucky; San Antonio, Texas; Ohio; Meridian, Idaho; Fort Worth, Texas; New Mexico; Augusta, Georgia; Idaho Falls, Idaho; Orem, Utah; New York; Chandler, Arizona; Racine, Wisconsin; Iowa; Madison, Wisconsin; Grand Rapids, Michigan; Cedar Rapids, Iowa; Atlanta, Georgia; Everett, Washington; Layton, Utah; Santa Fe, New Mexico; Sterling Heights, Michigan; Warren, Michigan; Lincoln, Nebraska; Sioux City, Iowa; Cincinnati, Ohio; Roswell, New Mexico; Kearney, Nebraska; Rochester, New York; Detroit, Michigan; Bellevue, Washington; Cleveland, Ohio; Idaho; Lexington-Fayette, Kentucky; Covington, Kentucky; Kentucky; Utah; Miami, Florida; Orlando, Florida; Owensboro, Kentucky; West Valley City, Utah; Salt Lake City, Utah; Kenosha, Wisconsin; Louisville, Kentucky; Omaha, Nebraska; Columbus, Ohio; Columbus, Georgia; Dayton, Ohio; Georgia; Syracuse, New York; Macon, Georgia; Milwaukee, Wisconsin; Rio Rancho, New Mexico; Tucson, Arizona; Iowa City, Iowa; Albuquerque, New Mexico; Yonkers, New York; Grand Island, Nebraska; Houston, Texas; Phoenix, Arizona; Florida; Nampa, Idaho; Green Bay, Wisconsin; St. Petersburg, Florida; Davenport, Iowa; Ann Arbor, Michigan; Des Moines, Iowa; Akron, Ohio; Jacksonville, Florida; Nebraska; Washington; Las Cruces, New Mexico; Buffalo, New York; Vancouver, Washington; Austin, Texas; Caldwell, Idaho; Boise, Idaho; Savannah, Georgia; Wisconsin; Dallas, Texas; Mesa, Arizona; Tampa, Florida; Tacoma, Washington; Texas Job ID 2032021JOB 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: 06/17/2025ABOUT OUR LOCATION
View Map- Specialist, Appeals & Grievances Kenosha Wisconsin, Akron Ohio, Phoenix Arizona, Florida, Lincoln Nebraska, Columbus Ohio, Tucson Arizona, Yonkers New York, Houston Texas, Bellevue Nebraska, Dallas Texas, Louisville Kentucky, Fort Worth Texas, Iowa City Iowa, San Antonio Texas, Albuquerque New Mexico, Grand Rapids Michigan, Nampa Idaho, Kearney Nebraska, Macon Georgia, Idaho Falls Idaho, Sterling Heights Michigan, Spokane Washington, Boise Idaho, Tampa Florida, Las Cruces New Mexico, Ann Arbor Michigan, Orlando Florida, Detroit Michigan, Savannah Georgia, Provo Utah, Milwaukee Wisconsin, Bellevue Washington, Meridian Idaho, Cleveland Ohio, Syracuse New York, Michigan, Ohio, Kentucky, New Mexico, Columbus Georgia, Wisconsin, Salt Lake City Utah, Lexington-Fayette Kentucky, West Valley City Utah, Tacoma Washington, Davenport Iowa, Texas, Idaho, Augusta Georgia, Austin Texas, Mesa Arizona, Santa Fe New Mexico, Green Bay Wisconsin, Omaha Nebraska, Georgia, Roswell New Mexico, Rochester New York, Miami Florida, Caldwell Idaho, Owensboro Kentucky, Rio Rancho New Mexico, Des Moines Iowa, Jacksonville Florida, Bowling Green Kentucky, Orem Utah, Madison Wisconsin, New York, Nebraska, Racine Wisconsin, Grand Island Nebraska, Buffalo New York, Everett Washington, Albany New York, Warren Michigan, Cincinnati Ohio, Layton Utah, Sioux City Iowa, Covington Kentucky, St. Petersburg Florida, Washington, Iowa, Cedar Rapids Iowa, Atlanta Georgia, Vancouver Washington, Scottsdale Arizona, Chandler Arizona, Dayton Ohio, Utah 07/08/2025
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