Remote Claims Appeals Lead - Medicare/Medicaid

Molina Healthcare, Inc.; Oregon; Hybrid; USD 60,000 - 90,000; Full time

Job summary

Molina Healthcare, Inc. seeks a lead-level claims support specialist to review and resolve member and provider complaints in compliance with CMS standards. The role operates in Pacific Time with an 8am–5pm PT shift. Based in Oregon, you will guide a team through appeals, grievances, and related workflows.

Ideal candidates have 3+ years in managed care claims, Medicaid/Medicare denials experience, strong customer service, and solid communication skills, with proficiency in Microsoft Office.

Qualifications

• 3+ years of managed care in call center, appeals, and/or claims.
• Health claims processing with benefits coordination and eligibility.
• Experience with Medicaid/Medicare denials and appeals processing.
• Strong customer service experience.
• Excellent organizational and time-management skills.
• Strong verbal and written communication skills.
• Proficiency in Microsoft Office and related software.

Responsibilities

• Lead handling of appeals, grievances, and complaints from members, providers, and outside agencies.
• Trains new staff and guides others on complex appeals and grievances.
• Resolves escalated issues including state complaints and high-visibility cases.
• Collaborates with claims leadership to assign work to team.
• Prepares appeal summaries, correspondence, and tracking data.
• Prepares drafts for narratives, graphs, flowcharts for audits and presentations.
• Requests and reviews records and bills; determines responses per protocols.
• Meets production standards in claims processing.
• Applies contract language and review of benefits and covered services.
• Contacts members and providers as needed.
• Documents findings and trends when requested.
• Writes correspondence and disputes per regulatory requirements.
• Researches processing guidelines and contracts to identify root causes.
• Responds to provider reconsideration requests and pay adjustments.

Skills

Managed care experience

Health claims processing

Medicaid/Medicare denials

Customer service

Organizational & time management

Verbal & written communication

Microsoft Office

Tools

Microsoft Office

Job description

Molina Healthcare, Inc. seeks a lead-level claims support specialist to review and resolve member and provider complaints in compliance with CMS standards. The role operates in Pacific Time with an 8am–5pm PT shift. Based in Oregon, you will guide a team through appeals, grievances, and related workflows.

Ideal candidates have 3+ years in managed care claims, Medicaid/Medicare denials experience, strong customer service, and solid communication skills, with proficiency in Microsoft Office.