Manager, Appeals & Grievances Member- Remote EST

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

Job summary

Molina Healthcare is seeking a senior manager to lead a team responsible for claims activities, including reviewing and resolving member and provider complaints in accordance with CMS standards. The role emphasizes regulatory compliance, performance dashboards, and timely resolutions.

The position requires extensive managed care, leadership, and claims experience, with strong customer service, organizational, and communication skills.

Qualifications

• 7+ years of managed care experience in call center, appeals, and/or claims environment or equivalent
• 1+ year of management/leadership experience
• Experience reviewing a wide range of medical claims (HCFA 1500, UB92, etc.)
• Experience with Medicaid/Medicare claims denials and appeals processing
• Experience leading projects
• Strong customer service experience
• Strong organizational and time management skills
• Strong verbal and written communication skills
• Proficiency with MS Office or applicable software

Responsibilities

• Lead and manage team responsible for submission/resolution of member and provider appeals and grievances in line with CMS standards
• Assess and audit business processes to improve grievance resolution efficiency
• Serve as primary interface with stakeholders and ensure standard processes are implemented
• Oversee preparation of narratives, graphs, flowcharts for committees, audits, and reports; oversee applicable correspondence
• Ensure claims production standards set by the department are met
• Maintain call tracking system and monitor appeals to meet timelines

Skills

Managed care experience

Leadership

Claims review

Regulatory knowledge

Project leadership

Customer service

Time management

Verbal & written communication

MS Office

Job description

Must be flexable to travel to the SC office when needed due to buisnsess needs

JOB DESCRIPTION Job Summary

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.