Associate Specialist, Appeals & Grievances

Job Overview

This role provides foundational support for claims-related tasks, which includes reviewing and resolving grievances from members and providers. The specialist communicates outcomes to members or their authorized representatives while adhering to the guidelines set by the Centers for Medicare and Medicaid Services (CMS).

Key Responsibilities

• Input denial and appeal requests into the information system and prepare necessary documentation for subsequent reviews.
• Investigate claim matters using available systems and resources.
• Ensure appeals are processed timely and comply with state, federal, and organizational policies.
• Request and collect medical documentation such as records, notes, and billing details to assist with claim research.
• Compose appropriately worded letters responding to member appeals and grievances.
• Escalate appeals needing further review to higher levels.
• Prepare and dispatch denial notification letters.
• Support resolution of interdepartmental issues efficiently by promoting collaboration.
• Maintain and generate reports and statistics related to appeals and grievances.
• Work with provider and member service teams to address balance billing and other complaints.

Required Qualifications

• Minimum one year experience in claims processing and/or at least one year in customer or provider services within the health care industry, or a comparable blend of education and experience.
• Proven customer service skills.
• Strong organizational and time management abilities to handle multiple tasks and meet deadlines.
• Effective communication, both verbal and written.
• Familiarity with Microsoft Office and relevant software applications.

Preferred Qualifications

• Experience within managed care organizations (Medicaid, Medicare, Marketplace, or other government programs) or medical offices/hospitals.
• Completion of a vocational healthcare program like medical coding, billing, or medical assistance.

Compensation

This position offers an hourly wage between $13.41 and $29.06. Actual pay varies based on location, experience, education, and skill level.

Additional Information

Molina Healthcare provides a competitive benefits and compensation package and is an Equal Opportunity Employer (M/F/D/V). Current Molina employees should apply through the internal job board.