Appeals & Grievances Resolution Specialist

Molina Healthcare; Kentucky; On-site; USD 22,000 - 43,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare in West Virginia is seeking a Claims Appeals Specialist to support member and provider claims activities, review disputes, and communicate resolutions in accordance with CMS standards.

The role focuses on researching appeals, grievances, and denials, coordinating necessary documentation, and ensuring timely, accurate responses while maintaining high service quality within regulatory guidelines.

Qualifications

• At least 2 years managed care experience in appeals and/or claims environment.
• Health claims processing experience including coordination of benefits (COB) and subrogation.
• Experience with Medicaid/Medicare claims denials and appeals processing.
• Customer service experience.
• Strong organizational and time-management skills to manage multiple projects and meet deadlines.
• Effective verbal and written communication skills.
• Proficiency with Microsoft Office suite.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances and/or complaints to meet regulatory timelines.
• Researches claims, appeals, and grievances to determine outcomes.
• Reviews medical records and bills, formulates conclusions per protocol, and communicates responses.
• Prepares appeal summaries and correspondence, documents findings.
• Resolves and responds to provider reconsideration requests related to claims payment.
• Contacts members/providers to obtain information as needed.

Skills

Managed care experience

Claims processing

Customer service

Time management

Verbal & written communication

MS Office

Job description

Molina Healthcare in West Virginia is seeking a Claims Appeals Specialist to support member and provider claims activities, review disputes, and communicate resolutions in accordance with CMS standards.

The role focuses on researching appeals, grievances, and denials, coordinating necessary documentation, and ensuring timely, accurate responses while maintaining high service quality within regulatory guidelines.