Member Appeals & Grievances Specialist

Molina Healthcare; United States; Remote; USD 55,000 - 75,000; Full time

Job summary

Molina Healthcare is seeking a Specialist to support member appeals and grievances, resolving disputes under CMS standards. You will research, review records, and communicate timely resolutions to members or authorized representatives.

The role requires experience in managed care with Medicaid/Medicare denials, strong organizational and communication skills, and proficiency in Microsoft Office. This is a full-time position supporting end-to-end appeals processes.

Qualifications

• At least 2 years of managed care experience in appeals or claims.
• Health claims processing experience including COB and eligibility.
• Experience with Medicaid/Medicare denials and appeals processing.

Responsibilities

• Researches and resolves member/provider appeals and grievances to meet timelines.
• Reviews medical records and bills to determine appeal outcomes.
• Communicates resolutions to members or authorized representatives.
• Prepare appeal summaries and correspondence per regulatory requirements.
• Researches guidelines to determine root causes of payment errors.
• Resolves provider reconsideration requests related to payments.

Skills

Managed care experience

Customer service

Organizational skills

Verbal and written communication

MS Office proficiency

Tools

Microsoft Office Suite

Job description

Molina Healthcare is seeking a Specialist to support member appeals and grievances, resolving disputes under CMS standards. You will research, review records, and communicate timely resolutions to members or authorized representatives.

The role requires experience in managed care with Medicaid/Medicare denials, strong organizational and communication skills, and proficiency in Microsoft Office. This is a full-time position supporting end-to-end appeals processes.