Manager, Appeals & Grievances Member - Remote

Molina Healthcare; Northern (KY); Hybrid; USD 54,000 - 118,000; Full time

Job summary

Molina Healthcare is seeking a senior leader to manage a team focused on member and provider appeals and grievances in a CMS-compliant environment. The role requires deep expertise in Medicaid/Medicare claims handling and denials management.

The candidate will oversee investigations, prepare reports for committees, and ensure timely resolutions while maintaining excellent client service and regulatory adherence.

Qualifications

• At least 7 years of managed care experience in claims or appeals.
• At least 1 year of management/leadership experience.
• Experience reviewing a wide range of medical claims (HCFA 1500, UB92, etc.).
• Experience with Medicaid/Medicare denials and appeals processing.
• Experience leading projects.
• Strong customer service and communication skills.
• Proficiency in Microsoft Office suite.
• Ability to manage multiple projects to deadlines.

Responsibilities

• Lead team handling submission/resolution of member and provider appeals.
• Ensure resolutions comply with CMS standards and requirements.
• Audit processes to determine effective resolution of grievances.
• Interface with stakeholders and ensure standard processes are implemented.
• Prepare narratives, graphs, flowcharts, and reports for committees and audits.
• Ensure claims production standards are met by the department.
• Maintain call tracking and monitor appeals to meet regulatory timelines.

Skills

Managed care

Call center

Leadership

Regulatory knowledge

Medicare/Medicaid

Claims review

Project leadership

Customer service

Time management

MS Office

Education

Health care vocational program

Tools

MS Office

Job description

JOB DESCRIPTION Job Summary

Member Focus

Leads and manages team responsible 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

• Manages team responsible for the submission/resolution of member and provider appeals and grievances; ensures resolutions are compliant with applicable standards and requirements.
• Assesses and audits business processes to determine effective and efficient resolution of member and provider grievances.
• Serves as primary interface with stakeholders and business partners, and ensures standard processes are implemented.
• Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.
• Ensures claims production standards set by the department are met.
• Maintains call tracking system of correspondence and outcomes for provider and member appeals/grievances; oversees/monitors appeals to ensure all internal and regulatory timelines are met.

Required Qualifications

• At least 7 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
• At least 1 year management/leadership experience.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high-dollar complicated claims, COB and DRG/RCC pricing).
• Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Previous experience leading projects.
• 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

Pay Range: $54,373.27 - $117,808.76 / ANNUAL
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.