Specialist, Appeals & Grievances

Job summary

This position supports claims-related work by investigating and resolving complaints from members and providers, then communicating outcomes to the member or an authorized representative in line with CMS standards and requirements.

What you will do

• Handle a full range of appeals, disputes, grievances, and complaints from members, providers, and outside agencies while staying within internal and regulatory turnaround times.
• Use internal systems to investigate claims appeals and grievance cases and determine the appropriate outcome.
• Obtain and review medical records, case notes, and detailed bills when needed, then build a response based on protocol and input from business partners while meeting state, federal, and Molina guidelines.
• Work to department production expectations for claims activity.
• Interpret contract terms, benefits, and covered-service rules as part of the claims review process.
• Reach out to members and providers through written or spoken communication when additional information or clarification is required.
• Draft appeal summaries, correspondence, and case documentation, including trend information when requested.
• Prepare clear, accurate correspondence for appeals, disputes, and grievances in line with regulatory standards.
• Review claims handling rules, provider agreements, fee schedules, and system settings to identify the source of payment issues.
• Respond in writing to provider reconsideration requests, claim adjustment requests, and inquiries from outside agencies.

Required background

Applicants should bring managed care, claims, or call center experience, along with familiarity with health claims processing and appeals/denials workflows. The role also calls for strong customer service ability, organization, communication skills, and comfort using Microsoft Office and related software.

Preferred background

Helpful experience includes working with customers or providers in a managed care organization, such as Medicaid, Medicare, Marketplace, or another government-funded program, or in a medical office or hospital environment. A vocational credential in a health care field such as coding, billing, or medical assisting is also preferred.

Additional information

Current Molina employees who want to be considered for this role should apply through the internal job board. The company states that it provides a competitive compensation and benefits package and is an equal opportunity employer.

Compensation

The posted hourly pay range is $14.76 to $31.97. Final pay may differ based on location, work experience, education, and skill level.