Claims Appeals & Grievances Specialist

Molina Talent Acquisition; Florida; On-site; USD 22,000 - 43,000; Full time

Job summary

Join Molina Healthcare as a Claims Appeals Specialist in Florida. You will research and resolve appeals, disputes, and grievances for Molina members and providers, ensuring timely responses and compliance with state and federal guidelines.

You'll review medical records and bills, prepare appeal summaries, and coordinate with internal teams to determine outcomes. Strong organization, customer service, and Microsoft Office skills are essential for success in this role.

Qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment.
• Health claims processing experience, including COB, subrogation and eligibility.
• Experience with Medicaid and Medicare claims denials and appeals processing; regulatory knowledge.
• Customer service experience.
• Strong organizational and time management skills; can manage multiple deadlines.
• Effective verbal and written communication skills.
• Proficiency with Microsoft Office suite.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances for Molina members/providers to meet timelines.
• Researches claims appeals and grievances using systems to determine outcomes.
• Requests and reviews medical records and bills; determines response per protocol and guidelines.
• Meets claims production standards set by the department.
• Applies contract language, benefits and review of services to claims review.
• Contacts members/providers via written and verbal communications.
• Prepares appeal summaries and documents findings, including trends.
• Composes correspondence and appeals information in accordance with requirements.
• Researches processing guidelines to determine root causes of payment errors.
• Resolves and writes responses to provider reconsideration requests related to payments/adjustments.

Skills

Managed care experience

Call center experience

Customer service experience

Time management

Verbal and written communication

Microsoft Office proficiency

Education

Healthcare-related vocational program

Tools

Microsoft Office

Job description

Join Molina Healthcare as a Claims Appeals Specialist in Florida. You will research and resolve appeals, disputes, and grievances for Molina members and providers, ensuring timely responses and compliance with state and federal guidelines.

You'll review medical records and bills, prepare appeal summaries, and coordinate with internal teams to determine outcomes. Strong organization, customer service, and Microsoft Office skills are essential for success in this role.