Director, Appeals & Grievances
Molina Healthcare Ohio; New York; South Carolina; Mississippi; Meridian, Idaho; Sterling Heights, Michigan; Detroit, Michigan; Grand Island, Nebraska; Omaha, Nebraska; Las Cruces, New Mexico; New Mexico; Layton, Utah; Spokane, Washington; Madison, Wisconsin; Tucson, Arizona; Lincoln, Nebraska; Yonkers, New York; Austin, Texas; Houston, Texas; San Antonio, Texas; Salt Lake City, Utah; Provo, Utah; Utah; West Valley City, Utah; Bellevue, Washington; Vancouver, Washington; Racine, Wisconsin; Mesa, Arizona; Florida; Tampa, Florida; Sioux City, Iowa; Caldwell, Idaho; Idaho Falls, Idaho; Lexington-Fayette, Kentucky; Grand Rapids, Michigan; Nebraska; Bellevue, Nebraska; Rio Rancho, New Mexico; Albuquerque, New Mexico; Rochester, New York; Fort Worth, Texas; Texas; Everett, Washington; Washington; Orlando, Florida; Georgia; Macon, Georgia; Cedar Rapids, Iowa; Iowa City, Iowa; Boise, Idaho; Bowling Green, Kentucky; Owensboro, Kentucky; Ann Arbor, Michigan; Akron, Ohio; Columbus, Ohio; Orem, Utah; Kenosha, Wisconsin; Atlanta, Georgia; Roswell, New Mexico; Syracuse, New York; Cincinnati, Ohio; Scottsdale, Arizona; Jacksonville, Florida; St. Petersburg, Florida; Miami, Florida; Columbus, Georgia; Des Moines, Iowa; Idaho; Dayton, Ohio; Tacoma, Washington; Wisconsin; Davenport, Iowa; Iowa; Kentucky; Warren, Michigan; Michigan; Kearney, Nebraska; Albany, New York; Dallas, Texas; Milwaukee, Wisconsin; Augusta, Georgia; Savannah, Georgia; Nampa, Idaho; Covington, Kentucky; Louisville, Kentucky; Santa Fe, New Mexico; Buffalo, New York; Cleveland, Ohio; Green Bay, Wisconsin; Phoenix, Arizona; Chandler, Arizona Job ID 2031035
Job 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 member appeals and grievance processing/resolution, including 2 years in a manager role.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
2 years supervisory/management experience with appeals/grievance processing within a managed care setting.
Required License, Certification, Association
N/A
Preferred Education
Bachelor's Degree
Preferred Experience
N/A
Preferred License, Certification, Association
N/A
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.
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 member appeals and grievance processing/resolution, including 2 years in a manager role.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
2 years supervisory/management experience with appeals/grievance processing within a managed care setting.
Required License, Certification, Association
N/A
Preferred Education
Bachelor's Degree
Preferred Experience
N/A
Preferred License, Certification, Association
N/A
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 - $227,679 / 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: 04/01/2025ABOUT OUR LOCATION
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