Appeals & Grievances Specialist with Medicaid/Marketplace Expertise

Job Summary Join our dynamic team as an Appeals & Grievances Specialist, where you'll play a crucial role in ensuring exceptional service to our members and providers. Your responsibilities will include navigating the complexities of claims activities, resolving issues, and communicating outcomes in line with the standards set by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties Conduct in-depth research and resolution of appeals, grievances, and complaints from Molina members and providers, ensuring compliance with internal and regulatory timelines. Utilize support systems to analyze claims appeals and determine their outcomes effectively. Request and review medical records and billing details to form responses according to protocols and engage with other business partners as needed. Consistently meet claims production standards established by the department. Review contract language and benefits in relation to the claims processing procedure. Maintain communication with members and providers through concise written and verbal interactions. Prepare comprehensive appeal summaries and documentation, including data trends as required. Compose correspondence and dispute documentation in strict accordance with regulatory requirements. Investigate claims processing guidelines and provider contracts to identify causes of payment discrepancies. Address incoming provider reconsideration requests for claims adjustments and interactions with external agencies. Required Qualifications A minimum of 2 years' experience in managed care, particularly in call center, appeals, or claims roles, or a related educational background. Knowledge and hands-on experience in health claims processing, including coordination of benefits (COB) and eligibility criteria. Familiarity with Medicaid and Medicare claims denials and appeal processes, alongside a strong understanding of related regulatory guidelines. Proficient in customer service dynamics. Excellent organizational and time management abilities, capable of managing multiple projects to meet deadlines. Strong verbal and written communication skills. Proficiency in Microsoft Office suite and other relevant software applications. Preferred Qualifications Direct experience with customers/providers in a managed care setting, including Medicaid, Medicare, and marketplace programs. Completion of a healthcare vocational program (e.g., certified coder, billing specialist, or medical assistant). All current Molina employees interested in this position should apply through the Internal Job Board. Molina Healthcare provides a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range:

$21.65 - $38.37 / HOURLY *Actual compensation may vary based on geographic location, work experience, education, and/or skill level.