Manager, Appeals & Grievances Member- Remote EST

Molina Healthcare; United States; Remote; USD 110,000 - 150,000; Full time

Job summary

Molina Healthcare is seeking an experienced leader to manage a claims appeals team and resolve member and provider issues in alignment with CMS guidelines. The role combines strategic oversight with hands-on process improvement across claims workflows.

You will interface with stakeholders, prepare narratives and reports, and monitor timelines to meet regulatory requirements. Strong communication, organizational skills, and a track record in managed care are essential to drive outcomes for

Qualifications

• At least 7 years in managed care claims/appeals environment.
• At least 1 year of management/leadership experience.
• Experience reviewing a wide range of medical claims (HCFA 1500, UB92, etc.).

Responsibilities

• 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.]
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Skills

Managed care experience

Leadership

Customer service

Communication

Time management

MS Office

Tools

Microsoft 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