Specialist, Appeals & Grievances (Claims)

Molina Talent Acquisition; Florida; Sur place; USD 22 000 - 43 000; Plein temps

Résumé du poste

Join Molina Healthcare as a Claims Appeals Specialist in Florida. You will research and resolve appeals, disputes, and grievances for Molina members and providers, ensuring timely responses and compliance with state and federal guidelines.

You'll review medical records and bills, prepare appeal summaries, and coordinate with internal teams to determine outcomes. Strong organization, customer service, and Microsoft Office skills 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.
• Health claims processing experience, including COB, subrogation and eligibility.
• Experience with Medicaid and Medicare claims denials and appeals processing; regulatory knowledge.
• Customer service experience.
• Strong organizational and time management skills; can manage multiple deadlines.
• Effective verbal and written communication skills.
• Proficiency with Microsoft Office suite.

Responsabilités

• Facilitates research and resolution of appeals, disputes, grievances for Molina members/providers to meet timelines.
• Researches claims appeals and grievances using systems to determine outcomes.
• Requests and reviews medical records and bills; determines response per protocol and guidelines.
• Meets claims production standards set by the department.
• Applies contract language, benefits and review of services to claims review.
• Contacts members/providers via written and verbal communications.
• Prepares appeal summaries and documents findings, including trends.
• Composes correspondence and appeals information in accordance with requirements.
• Researches processing guidelines to determine root causes of payment errors.
• Resolves and writes responses to provider reconsideration requests related to payments/adjustments.

Connaissances

Managed care experience

Call center experience

Customer service experience

Time management

Verbal and written communication

Microsoft Office proficiency

Formation

Healthcare-related vocational program

Outils

Microsoft Office

Description du poste

Job Description

JOB DESCRIPTION Job Summary

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).

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

Job Info

• Job Identification 2039805
• Job Category Operations
• Posting Date 10/16/2026, 03:16 PM
• Job Schedule Full time
• Locations FL, United States Orlando, FL, United States Jacksonville, FL, United States Tampa, FL, United States Miami, FL, United States
• Salary Range $16.40 - $31.97 Hourly *Actual compensation may vary based on geographic location, work experience, education and/or skill level