Lead Specialist, Appeals & Grievances (Remote)

Molina Healthcare; United States; Remote; USD 65,000 - 105,000; Full time

Benefits offered by this job

Competitive benefits

Equal Opportunity Employer

Job summary

Molina Healthcare is seeking a lead-level claims support professional to supervise review and resolution of member and provider complaints in compliance with CMS standards. You will coordinate appeals and grievances, guide team members, and ensure accurate documentation and timely responses.

The role requires 3+ years in managed care claims or appeals, strong customer service, and proficiency with Microsoft Office and claims systems. Equal Opportunity Employer.

Qualifications

• 3+ years in managed care claims or appeals environment.
• Experience with Medicaid/Medicare claims denials and appeals.
• Strong customer service and communication skills.

Responsibilities

• Lead team in submission, intervention and resolution of appeals and grievances.
• Train new employees and guide complex cases.
• Prepare summaries, narratives, and documentation for audits.
• Ensure timely responses per CMS guidelines.
• Monitor performance against production standards.

Skills

Managed care experience

Call center experience

Claims processing

Regulatory knowledge CMS

Customer service

Verbal and written communication

Tools

Microsoft Office

Claims processing systems

Job description

JOB DESCRIPTION

Job Summary

Provides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).

Essential Job Duties

• Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies.
• Trains new employees and provides guidance to others with respect to complex appeals and grievances.
• Researches and resolves escalated issues including state complaints and high visible complex cases.
• In conjunction with claims leadership, assigns claims work to team.
• Prepares appeal summaries and correspondence, and documents information for tracking/trending data.
• Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines.
• Meets claims production standards set by the department.
• Applies contract language, benefits, and review of covered services.
• Contacts members/providers via written and verbal communications as needed.
• Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested.
• Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements.
• Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors.
• Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies.

Required Qualifications

• At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
• Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria.
• Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Strong customer service experience.
• Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting.
• Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.