CMS-Compliant Appeals & Grievances Lead

Molina Healthcare, Inc.; United States; Remote; USD 90,000 - 130,000; Full time

Benefits offered by this job

Competitive benefits

Equal Opportunity Employer

Job summary

Molina Healthcare, Inc. is seeking a Claims Operations Supervisor to lead a team responsible for the submission and resolution of member and provider appeals and grievances in accordance with CMS standards.

This role oversees documentation, reporting, and adherence to regulatory timelines within a fast-paced managed care environment. The candidate will drive process improvements, coordinate with corporate and member services, and ensure production standards are met while maintaining excellent

Qualifications

• At least 4 years of operational managed care experience in a call center, appeals, and/or claims environment.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims).
• Experience with Medicaid and Medicare claims denials and appeals processing.
• Previous experience leading projects.
• Strong verbal and written communication skills.
• Strong customer service experience.
• Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet deadlines.
• Proficiency with Microsoft Office suite.

Responsibilities

• Supervises team responsible for submission/resolution of member and provider appeals and grievances in line with CMS standards.
• Assesses and audits business processes to improve grievance resolution.
• Interfaces with corporate counterparts and member services to align with guidelines.
• Oversees preparation of narratives, graphs, and reports for committees and audits; manages required correspondence.
• Ensures claims production standards set by the department are met.
• Maintains call tracking system and database of correspondence and outcomes for provider and member appeals; tracks regulatory timelines.

Skills

Verbal communication

Written communication

Customer service

Organization & time management

MS Office

Project management

Managed care experience

Tools

Microsoft Office

Job description

Molina Healthcare, Inc. is seeking a Claims Operations Supervisor to lead a team responsible for the submission and resolution of member and provider appeals and grievances in accordance with CMS standards.

This role oversees documentation, reporting, and adherence to regulatory timelines within a fast-paced managed care environment. The candidate will drive process improvements, coordinate with corporate and member services, and ensure production standards are met while maintaining excellent