Claims Appeals & Grievances Specialist

Molina Healthcare; Florida; Remote; USD 45,000 - 60,000; Full time

Job summary

Molina Healthcare in Florida is seeking a Claims Support Specialist to review and resolve member and provider complaints, ensuring timely responses under CMS guidelines and internal standards.

You will research appeals and grievances, request and review medical records, communicate resolutions to members or authorized representatives, and prepare detailed summaries and correspondence that document findings and trends while maintaining compliance.

Qualifications

• 2+ years in a managed care, call center, appeals or claims environment.
• Experience with Medicaid/Medicare claims denials and appeals processing.
• Experience in customer service.
• Strong organizational and time management skills.
• Effective verbal and written communication skills.
• Proficiency with Microsoft Office and related software.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and complaints from Molina members, providers, and related outside agencies.
• Researches claims appeals and grievances using support systems to determine outcomes.
• Requests and reviews medical records, notes, and detailed bills; formulates conclusions per protocol and stakeholders.
• Meets claims production standards set by the department.
• Applies contract language and review of benefits to claims review process.
• Communicates with members/providers via written and verbal channels.
• Prepares appeal summaries and correspondence documenting findings and trends.

Skills

Organizational skills

Time management

Verbal communication

Written communication

Education

Healthcare vocational program certification (coder/billing/medical assistant)

Tools

Microsoft Office

Job description

Molina Healthcare in Florida is seeking a Claims Support Specialist to review and resolve member and provider complaints, ensuring timely responses under CMS guidelines and internal standards.

You will research appeals and grievances, request and review medical records, communicate resolutions to members or authorized representatives, and prepare detailed summaries and correspondence that document findings and trends while maintaining compliance.