Appeals & Grievances Specialist — Claims Resolution

Molina Healthcare; Northern (KY); Hybrid; USD 19,000 - 44,000; Full time

Job summary

Molina Healthcare in Kentucky is seeking a Claims Support role focused on researching and resolving member and provider complaints in compliance with CMS standards.

Responsibilities include appeals and dispute resolution, reviewing medical records and bills, and communicating timely outcomes to members and providers. Must have strong organization, customer service, and knowledge of Medicaid/Medicare claims processing.

Qualifications

• At least 2 years of managed care experience in claims/appeals environment or equivalent.
• Health claims processing experience including COB, subrogation and eligibility.
• Experience with Medicaid and Medicare claims denials and appeals.
• Customer service experience is required.
• Strong organizational and time management skills to manage multiple tasks.

Responsibilities

• Researches and resolves appeals, disputes, grievances, and complaints to meet internal and regulatory timelines.
• Researches claims appeals and grievances using support systems to determine outcomes.
• Requests and reviews medical records and detailed bills; determines responses.
• Meets claims production standards set by the department.
• Applies contract language and review of benefits in claims review processes.
• Contacts members/providers via written and verbal communications.
• Prepares appeal summaries and correspondence; documents findings.
• Composes all correspondence and regulatory-compliant information.
• Investigates processing guidelines to identify root causes of payment errors.
• Resolves provider reconsideration requests related to claims payments.

Skills

Managed care experience

Customer service

Verbal and written communication

Organizational skills

Microsoft Office proficiency

Tools

MS Office

Job description

Molina Healthcare in Kentucky is seeking a Claims Support role focused on researching and resolving member and provider complaints in compliance with CMS standards.

Responsibilities include appeals and dispute resolution, reviewing medical records and bills, and communicating timely outcomes to members and providers. Must have strong organization, customer service, and knowledge of Medicaid/Medicare claims processing.