Specialist, Appeals & Grievances
Molina Healthcare Nebraska; Kentucky; New York; Idaho; Florida; Wisconsin; New Mexico; Ohio; Utah; Washington; Michigan; Texas; Georgia; Iowa; Bowling Green, Kentucky; Lexington-Fayette, Kentucky; Iowa City, Iowa; Columbus, Ohio; Caldwell, Idaho; Scottsdale, Arizona; Dallas, Texas; Fort Worth, Texas; Provo, Utah; Bellevue, Washington; Miami, Florida; Yonkers, New York; Lincoln, Nebraska; Omaha, Nebraska; Grand Island, Nebraska; Racine, Wisconsin; Tucson, Arizona; Austin, Texas; West Valley City, Utah; Layton, Utah; Vancouver, Washington; St. Petersburg, Florida; Jacksonville, Florida; Orlando, Florida; Covington, Kentucky; Augusta, Georgia; Kenosha, Wisconsin; Houston, Texas; Las Cruces, New Mexico; Grand Rapids, Michigan; Detroit, Michigan; Seattle, Washington; Sioux City, Iowa; Dayton, Ohio; Cincinnati, Ohio; Akron, Ohio; Madison, Wisconsin; Milwaukee, Wisconsin; Idaho Falls, Idaho; Roswell, New Mexico; Orem, Utah; Ann Arbor, Michigan; Tacoma, Washington; Owensboro, Kentucky; Cedar Rapids, Iowa; Atlanta, Georgia; Warren, Michigan; Rochester, New York; Bellevue, Nebraska; Davenport, Iowa; Des Moines, Iowa; Savannah, Georgia; Nampa, Idaho; Chandler, Arizona; San Antonio, Texas; Santa Fe, New Mexico; Sterling Heights, Michigan; New York, New York; Louisville, Kentucky; Cleveland, Ohio; Columbus, Georgia; Meridian, Idaho; Albuquerque, New Mexico; Rio Rancho, New Mexico; Salt Lake City, Utah; Spokane, Washington; Tampa, Florida; Syracuse, New York; Buffalo, New York; Kearney, Nebraska; Macon, Georgia; Green Bay, Wisconsin; Boise, Idaho; Phoenix, Arizona; Mesa, Arizona; Bothell, Washington Job ID 2031322JOB 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 denial research background, including coordination of benefits, subrogation, and eligibility criteria.
- Familiarity with Medicaid and Marketplace 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: 04/14/2025ABOUT OUR LOCATION
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