Specialist, Appeals & Grievances

Molina Healthcare; Bothell (WA); On-site; USD 30,000 - 51,000; Full time

Job summary

Molina Healthcare in Bothell, WA is seeking a Claims Appeals Specialist to support member and provider complaints, and to resolve appeals and denials in line with CMS standards.

The role emphasizes timely research, documentation, and communication of resolutions to stakeholders, with focus on accuracy and regulatory compliance.

Qualifications

• At least 2 years of managed care experience in claims/appeals environments.
• Health claims processing knowledge including COB, subrogation and eligibility.
• Experience with Medicaid/Medicare claims denials and appeals.
• Strong customer service experience and regulatory awareness.
• Excellent organizational and time management skills.
• Effective verbal and written communication; proficient with MS Office.

Responsibilities

• Researches and resolves appeals, disputes and grievances from Molina members and providers.
• Reviews medical records and notes to determine appropriate outcomes per protocol.
• Ensures timeliness and compliance with state, federal and Molina guidelines.
• Contacts members/providers and prepares appeal summaries and correspondence.
• Documents findings and trends for internal reporting.
• Resolves provider reconsideration requests related to claims payment.

Skills

Customer service

Verbal communication

Written communication

Tools

Microsoft Office

Job description

Job Description

Job Summary

Provides support 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

• Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met.
• Researches claims appeals and grievances using support systems to determine appropriate appeals and grievance outcomes.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines.
• Meets claims production standards set by the department.
• Applies contract language, benefits and review of covered services to claims review process.
• Contacts members/providers as needed via written and verbal communications.
• Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested).
• Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements.
• Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.
• Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies.

Required Qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
• Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria.
• Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Customer service experience.
• Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Effective 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).
• Billing Experience

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $21.78 - $36.77 / HOURLY

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.