Senior Appeals & Grievances Manager

Molina Healthcare; United States; Remote; USD 90,000 - 115,000; Full time

Job summary

Molina Healthcare is seeking a senior professional to lead a team focused on claims activities, appeals, and grievances in accordance with CMS standards. You will manage resolution processes, audits, and reporting, coordinating with stakeholders to meet regulatory timelines.

The role emphasizes strong leadership, customer service, andCompliance with healthcare regulations, with opportunities to guide process improvements and reporting initiatives.

Qualifications

• At least 7 years in managed care call center, appeals, and/or claims environment.
• At least 1 year of management/leadership experience.
• Experience reviewing 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 Microsoft Office or applicable software programs.

Responsibilities

• Manages team responsible for 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.

Skills

Managed care experience

Leadership experience

Claims review & resolution

Medicare/Medicaid knowledge

Project leadership

Customer service

Organization & time management

Verbal & written communication

MS Office proficiency

Job description

Molina Healthcare is seeking a senior professional to lead a team focused on claims activities, appeals, and grievances in accordance with CMS standards. You will manage resolution processes, audits, and reporting, coordinating with stakeholders to meet regulatory timelines.

The role emphasizes strong leadership, customer service, andCompliance with healthcare regulations, with opportunities to guide process improvements and reporting initiatives.