ATTENTION JOB SEEKERS AND MOLINA APPLICANTS: FRAUD ALERT
Be aware that third parties posing as Molina Healthcare may be soliciting money from job seekers and extending offers to candidates who have not interviewed. Molina does not engage in these type of practices. If you have received an offer and have not been engaging with Molina Healthcare in an interview process, reach out to erc@molinahealthcare.com to validate the legitimacy of your offer. Please note that Molina has reported this activity to the appropriate law enforcement agencies for further investigation. If you feel you’ve been victimized, please report it to local law enforcement.
Specialist, Appeals & Grievances (Medicare Appeals/Disputes)
Molina Healthcare Salt Lake City, Utah; Warren, Michigan; Iowa; Miami, Florida; Orlando, Florida; Everett, Washington; Nampa, Idaho; St. Petersburg, Florida; Bowling Green, Kentucky; San Antonio, Texas; Meridian, Idaho; Chandler, Arizona; Georgia; Louisville, Kentucky; Fort Worth, Texas; Columbus, Ohio; Augusta, Georgia; Detroit, Michigan; Caldwell, Idaho; West Valley City, Utah; Omaha, Nebraska; Jacksonville, Florida; Idaho Falls, Idaho; Santa Fe, New Mexico; Grand Rapids, Michigan; Wisconsin; Michigan; Florida; Mesa, Arizona; Tampa, Florida; Columbus, Georgia; Rochester, New York; Spokane, Washington; Savannah, Georgia; Covington, Kentucky; Ann Arbor, Michigan; Syracuse, New York; Las Cruces, New Mexico; Buffalo, New York; Utah; New Mexico; Cincinnati, Ohio; Des Moines, Iowa; Cedar Rapids, Iowa; Houston, Texas; Albany, New York; Bellevue, Nebraska; Lincoln, Nebraska; Tacoma, Washington; Green Bay, Wisconsin; Idaho; Madison, Wisconsin; Dallas, Texas; Kentucky; Rio Rancho, New Mexico; Austin, Texas; Iowa City, Iowa; Provo, Utah; Vancouver, Washington; Albuquerque, New Mexico; Yonkers, New York; Bellevue, Washington; Sioux City, Iowa; Phoenix, Arizona; Orem, Utah; Milwaukee, Wisconsin; Sterling Heights, Michigan; Nebraska; New York; Washington; Roswell, New Mexico; Kearney, Nebraska; Atlanta, Georgia; Scottsdale, Arizona; Boise, Idaho; Davenport, Iowa; Grand Island, Nebraska; Macon, Georgia; Cleveland, Ohio; Lexington-Fayette, Kentucky; Texas; Ohio; Kenosha, Wisconsin; Tucson, Arizona; Owensboro, Kentucky; Racine, Wisconsin; Dayton, Ohio; Akron, Ohio; Layton, Utah Job ID 2032287JOB DESCRIPTION
*Must be able to work 8am-5pm PST hours
*Must be able to rotate weekends and holidays
*Must have Medicare Appeals and IRE experience
Job Summary
Responsible for reviewing and resolving member appeals 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.
- 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
- Must have Medicare Member pre-service appeals 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: $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 06/24/2025Job Alerts
Sign up to receive automatic notices when jobs that match your interests are posted.