Claims Appeals & Grievances Specialist

Molina Talent Acquisition; Bothell (WA); On-site; USD 55,000 - 75,000; Full time

Job summary

Molina Healthcare is seeking a claims & appeals specialist to support CMS-aligned processes in resolving member and provider concerns. You'll review medical records, assess denials, and communicate timely resolutions to stakeholders.

Ideal candidates have 2+ years in managed care, strong customer service, and proficiency with claims systems and Microsoft Office. The role emphasizes regulatory adherence and cross-functional collaboration to meet deadlines.

Qualifications

• 2+ years in managed care call center, appeals, or claims.
• Experience with Medicaid/Medicare denials and appeals processing.
• Proficient with Microsoft Office and related software.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and complaints ensuring regulatory timelines are met.
• Researches claims appeals and grievances using support systems to determine outcomes.
• Requests and reviews medical records and bills to formulate conclusions per protocol.
• Meets claims production standards set by the department.
• Applies contract language and benefits to the review of claims.
• Contacts members/providers to communicate resolutions.
• Prepares appeal summaries and correspondence with findings.
• Composes correspondence and regulatory-compliant notices.
• Investigates guidelines and provider contracts to identify root causes of payment errors.
• Resolves provider reconsideration requests related to claims payment and adjustments.

Skills

Managed care

Call center experience

Appeals processing

Claims resolution

Customer service

Organizational skills

Communication skills

Education

Health care vocational program

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a claims & appeals specialist to support CMS-aligned processes in resolving member and provider concerns. You'll review medical records, assess denials, and communicate timely resolutions to stakeholders.

Ideal candidates have 2+ years in managed care, strong customer service, and proficiency with claims systems and Microsoft Office. The role emphasizes regulatory adherence and cross-functional collaboration to meet deadlines.