Member Appeals & Grievances Specialist - Medicaid/Medicare

Molina Healthcare, Inc.; Oregon; Hybrid; USD 42,000 - 64,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare, Inc. is seeking a Claims Support professional to review and resolve member and provider inquiries related to appeals, disputes, and grievances in accordance with CMS requirements.

Responsibilities include researching claims appeals, reviewing medical records and bills, and preparing timely responses and summaries. Excellent communication and strong organization are essential for success in this role.

Qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment.

Responsibilities

• Research and resolve appeals, disputes, grievances, and complaints to meet timelines.
• Research claims appeals and determine appropriate outcomes.
• Review medical records and bills to formulate responses per protocol.
• Prepare appeal summaries and correspondence with findings.
• Contact members/providers as needed via written or verbal communications.
• Identify root causes of payment errors and document findings.

Skills

Customer service

Verbal communication

Written communication

Time management

Organizational skills

Multitasking

Tools

Microsoft Office

Job description

Molina Healthcare, Inc. is seeking a Claims Support professional to review and resolve member and provider inquiries related to appeals, disputes, and grievances in accordance with CMS requirements.

Responsibilities include researching claims appeals, reviewing medical records and bills, and preparing timely responses and summaries. Excellent communication and strong organization are essential for success in this role.