Specialist, Appeals & Grievances

Molina Talent Acquisition; United States; On-site; USD 55,000 - 76,000; Full time

Job summary

Molina Healthcare is seeking a dedicated Appeals Specialist to support CMS-driven pre-service appeals across states. You will research and resolve appeals, communicate with members and providers, and prepare timely, compliant responses.

Requires 2+ years in managed care/claims environments, experience with Medicaid/Medicare denials, and strong organizational skills. This role emphasizes accuracy, timelines, and clear communication within a dynamic healthcare team.

Qualifications

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

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and/or complaints to ensure timelines are met.
• Researches claims appeals and grievances using support systems to determine outcomes.
• Requests and reviews medical records and detailed bills; formulates conclusions per protocol.
• Meets claims production standards set by the department.
• Applies contract language, benefits and review of covered services to claims review process.
• Contacts members/providers via written and verbal communications.
• Prepares appeal summaries and correspondence in compliance with regulations.
• Composes all correspondence and appeals information concisely and accurately.
• Researches claims processing guidelines to determine root causes of payment errors.
• Resolves and writes responses to provider reconsideration requests.

Skills

Managed care experience

Call center experience

Time management

Verbal and written communication

Microsoft Office proficiency

Customer service

Education

Health care vocational program

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job Summary

Provides support for pre service appeals for members across all states throughout the organization, communicating with members and providers 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

• Experience with appeals for Medicare and Medicaid and the regulations with CMS.


• Experience with pre authorization appeals.


• Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).


• Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting.

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