Senior Specialist, Appeals & Grievances Management

Job Summary Join our dedicated team as a Senior Specialist in Appeals & Grievances Management, where you will play a crucial role in resolving member and provider complaints efficiently. You will ensure that resolutions comply with the standards set by the Centers for Medicare and Medicaid Services (CMS), while actively contributing to high-quality claims support. Essential Job Duties Lead the team in managing submissions, interventions, and resolutions for appeals, grievances, and complaints from Molina members, providers, and relevant agencies. Provide training and guidance to new team members on handling complex appeals and grievances. Investigate and resolve escalated issues, including high-visibility cases and state complaints. Collaborate with claims leadership to effectively assign workload to the team. Document appeal summaries, correspondence, and track trends in data for analysis. Create visual aids such as graphs and flowcharts for presentations and audits, and conduct in-depth research on appeals outcomes. Request and review pertinent medical records and detailed bills to formulate accurate conclusions, ensuring compliance with timeliness protocols. Meet claims production standards while applying appropriate contract language and reviewing benefits and covered services. Communicate with members and providers through written and verbal means to provide necessary updates and information. Compile comprehensive summaries and documentation on appeals and grievances, highlighting trends when necessary. Thoroughly research claims processing guidelines, provider contracts, and system configurations to identify root causes of payment errors. Prepare written responses to provider reconsideration requests, addressing claims payments and adjustments efficiently. Required Qualifications Minimum of 3 years of experience in managed care, specifically 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. Knowledge of Medicaid and Medicare claims denials, along with the regulatory guidelines for appeals and denials. Strong customer service background with proven communication skills. Exceptional organizational and time management abilities to handle multiple projects and tasks effectively. 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.