Senior Specialist, Appeals and Grievances

Job Summary We invite you to join our dynamic team as a Senior Specialist in Appeals and Grievances, where you will play a vital role in effectively resolving member and provider complaints. Your expertise will ensure that resolutions adhere to the standards established by the Centers for Medicare and Medicaid Services (CMS) and will contribute to delivering exceptional claims support. Essential Job Duties Lead the team in successfully managing submissions, interventions, and resolutions for appeals, grievances, and complaints from Molina members, providers, and relevant agencies. Provide comprehensive training and guidance to new team members on navigating complex appeals and grievances. Investigate and resolve escalated issues, including high-visibility cases and state complaints with precision. Collaborate with claims leadership to efficiently assign workload to the team for optimal performance. Document appeal summaries, correspondence, and analyze data to track trends. Create engaging visual aids, such as graphs and flowcharts, for presentations and audits, and conduct thorough research on appeals outcomes. Request and review essential medical records and detailed bills to draw accurate conclusions, ensuring compliance with timeliness protocols. Meet claims production standards while adeptly applying appropriate contract language and reviewing benefits and covered services. Communicate effectively with members and providers through written and verbal means, ensuring timely updates and information flow. Compile detailed summaries and documentation on appeals and grievances, identifying trends as necessary. Conduct in-depth research on claims processing guidelines, provider contracts, and system configurations to uncover root causes of payment errors. Prepare clear written responses to provider reconsideration requests, addressing claims payments and adjustments efficiently. Required Qualifications Minimum of 3 years of experience in managed care, particularly in a call center, appeals, or claims environment, or a relevant combination of education and experience. Proven expertise in health claims processing, including coordination of benefits, subrogation, and eligibility criteria. Strong knowledge of Medicaid and Medicare claims denials, along with regulatory guidelines for appeals and denials. Exceptional customer service background complemented by proven communication skills. Outstanding organizational and time management skills to efficiently manage multiple projects and tasks. Proficiency in Microsoft Office and related software applications. Preferred Qualifications Experience in customer or provider service within a managed care organization or medical setting. Completion of a healthcare-related vocational program (e.g., certified coder, billing, or medical assistant). To all current Molina employees: If you wish to apply for this position, please do so through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $46.42 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level.