Appeals & Grievances Specialist

Job Summary Join our dedicated team as an Appeals & Grievances Specialist, where you will play a crucial role in supporting claims activities by addressing and resolving member and provider complaints. You will communicate resolutions in accordance with the standards set by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties Conduct thorough research to resolve appeals, disputes, grievances, and complaints from Molina members, providers, and outside agencies, ensuring compliance with internal and regulatory timelines. Utilize support systems to review claims appeals and grievances, determining appropriate outcomes effectively. Request and analyze medical records, notes, and detailed bills as necessary, formulating conclusions based on established protocols and collaborating with business partners to determine responses. Ensure all responses are timely and aligned with state, federal, and Molina guidelines. Meet and exceed claims production standards as established by the department. Apply contract language and benefits while reviewing claims for accuracy. Engage with members and providers through clear, concise written and verbal communication as needed. Prepare appeal summaries and documentation of findings, including trend information as required. Draft correspondence accurately, ensuring compliance with regulatory requirements. Investigate claims processing guidelines and provider contracts to identify root causes of payment errors. Resolve and document written responses to provider reconsideration requests concerning claims payments and adjustments. Required Qualifications Minimum of 2 years of experience in managed care within a call center, appeals, or claims environment, or an equivalent combination of education and experience. Experience in health claims processing, including coordination of benefits, subrogation, and knowledge of eligibility criteria. Familiarity with Medicaid and Medicare claims denials and appeal processes, including regulatory guidelines. Customer service experience is essential. Strong organizational and time management skills, with the ability to juggle multiple projects and tasks. Excellent verbal and written communication skills. Proficiency in Microsoft Office Suite and applicable software programs. Preferred Qualifications Experience in a managed care organization, medical office, or hospital setting. Completion of a healthcare-related vocational program (e.g., certified coder, billing, or medical assistant). This position is based in Bothell, WA. If you’re passionate about healthcare and looking for a fulfilling role, we encourage you to apply! Pay Range:

$21.65 - $36.77 / HOURLY *Actual compensation may vary based on geographic location, work experience, education, and skill level. Molina Healthcare is an Equal Opportunity Employer.