Specialist, Appeals & Grievances

Job Overview

This role focuses on providing comprehensive support for claims-related activities by addressing and resolving complaints and grievances filed by members and providers. Communication of resolutions follows strict adherence to the guidelines set forth by the Centers for Medicare and Medicaid Services (CMS).

Key Duties and Responsibilities

• Conduct thorough investigation and resolution of appeals, disputes, grievances, and complaints from members, providers, and external agencies, ensuring compliance with regulatory and organizational deadlines.
• Utilize various support systems to analyze claims appeals and grievances, determining accurate outcomes based on findings.
• Obtain and review pertinent medical records, billing documents, and notes to reach informed conclusions in collaboration with protocol standards and business partners, ensuring timely and appropriate responses according to state, federal, and Molina guidelines.
• Meet or exceed department-established claims production benchmarks.
• Interpret contract language, benefits, and coverage details during claims examination processes.
• Communicate effectively with members and providers via written correspondence and verbal contact as necessary.
• Draft appeal summaries and correspondence, meticulously documenting findings and incorporating trend data upon request.
• Prepare all communications related to appeals, disputes, and grievances with accuracy, clarity, and in line with regulatory mandates.
• Investigate claims processing rules, provider agreements, fee schedules, and system configurations to identify root causes of payment discrepancies.
• Address and respond to provider requests for reconsideration, claim adjustments, and external agency inquiries concerning claims payments.

Required Qualifications

• Minimum of two years' experience in managed care settings involving call center operations, appeals, or claims processing, or an equivalent blend of education and experience.
• Knowledge and experience in health claims processing, including coordination of benefits, subrogation, and eligibility evaluations.
• Familiarity with Medicaid and Medicare claims denial and appeal procedures, alongside regulatory compliance.
• Proven customer service skills.
• Strong organizational capabilities with effective time management to juggle multiple projects and deadlines.
• Excellent oral and written communication skills.
• Proficiency in Microsoft Office applications and comparable software tools.

Preferred Qualifications

• Exposure to managed care environments serving Medicaid, Medicare, Marketplace, or other government-funded programs, or experience within medical office or hospital contexts.
• Completion of vocational healthcare education programs such as certified coding, billing, or medical assisting.

Additional Information

Molina Healthcare provides a competitive compensation and benefits package and is an equal opportunity employer. Current Molina employees should apply internally via the designated job board.

Compensation

Hourly wage ranges between $14.76 and $31.97, subject to variation depending on location, experience, education, and skills.