Senior Specialist, Appeals & Grievances
Molina Healthcare Spokane, Washington; Everett, Washington; Cincinnati, Ohio; Racine, Wisconsin; Wisconsin; Utah; Chandler, Arizona; Washington; Kearney, Nebraska; Augusta, Georgia; Nampa, Idaho; Rio Rancho, New Mexico; Phoenix, Arizona; Cleveland, Ohio; Tacoma, Washington; St. Petersburg, Florida; Akron, Ohio; Jacksonville, Florida; Grand Rapids, Michigan; Texas; Columbus, Georgia; Bellevue, Nebraska; Idaho Falls, Idaho; Vancouver, Washington; Idaho; Tampa, Florida; Louisville, Kentucky; Fort Worth, Texas; Bowling Green, Kentucky; Salt Lake City, Utah; Lexington-Fayette, Kentucky; Michigan; Mesa, Arizona; Ohio; Orlando, Florida; Houston, Texas; Iowa; Meridian, Idaho; Owensboro, Kentucky; Macon, Georgia; Provo, Utah; San Antonio, Texas; Albuquerque, New Mexico; Ann Arbor, Michigan; Las Cruces, New Mexico; Florida; New Mexico; Madison, Wisconsin; Georgia; Cedar Rapids, Iowa; Austin, Texas; Caldwell, Idaho; Miami, Florida; West Valley City, Utah; Scottsdale, Arizona; Green Bay, Wisconsin; Covington, Kentucky; Dayton, Ohio; Layton, Utah; Warren, Michigan; Roswell, New Mexico; Detroit, Michigan; Yonkers, New York; Lincoln, Nebraska; Kentucky; Albany, New York; Orem, Utah; Iowa City, Iowa; Nebraska; Sterling Heights, Michigan; Dallas, Texas; Tucson, Arizona; Rochester, New York; Atlanta, Georgia; Boise, Idaho; Sioux City, Iowa; Milwaukee, Wisconsin; Kenosha, Wisconsin; Des Moines, Iowa; Santa Fe, New Mexico; Omaha, Nebraska; Davenport, Iowa; Buffalo, New York; New York; Syracuse, New York; Columbus, Ohio; Bellevue, Washington; Grand Island, Nebraska; Savannah, Georgia Job ID 2032233
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 and provider 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
- Responsible for the comprehensive research and resolution of the complex or escalated and high dollar appeals, grievances, and/or complaints from Molina members, providers and related outside agencies.
- 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 servicesÂ
- Responsible for contacting the member/provider through written and verbal communication.
- Prepares appeal summaries, correspondence, and document findings.Â
- Responsible for providing trends and identifying operational deficiencies found in the compliant.
- 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 (provider).
- 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 (Providers)
Job Qualifications
REQUIRED EDUCATION:
High School Diploma or equivalency
REQUIRED EXPERIENCE:
- Min. 3 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
PHYSICAL DEMANDS:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Â Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.
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 - $42.2 / 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: 06/23/2025ABOUT OUR LOCATION
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