Join Our Team as a Member Appeals & Grievances Specialist!
About the Role
We are seeking a proactive and detail-oriented Appeals & Grievances Specialist to become an essential part of our team! In this pivotal role, you will address and resolve member and provider complaints while ensuring effective communication and compliance with the standards set by the Centers for Medicare and Medicaid Services (CMS).
Your Key Responsibilities
Conduct thorough research to resolve appeals, grievances, and complaints from Molina members and providers, ensuring compliance with internal and regulatory timelines.
Analyze claims appeals and grievances using support systems to facilitate positive outcomes.
Request and review medical records and billing details as necessary, collaborating with business partners to reach conclusions aligned with established protocols and guidelines.
Achieve and exceed departmental claims production standards efficiently.
Interpret contract language and benefits accurately during the claims review process.
Communicate effectively with members and providers through verbal and written channels.
Draft clear appeal summaries and maintain detailed documentation of findings, including trend analyses when needed.
Prepare all appealing and grievance correspondence with accuracy while adhering to regulatory standards.
Investigate claims processing guidelines and provider contracts to identify root causes of payment discrepancies.
Address incoming provider reconsideration requests regarding claims payments and adjustments, managing external agency correspondence efficiently.
Who We're Looking For
A minimum of 2 years of experience in managed care, in roles such as a call center, appeals, or claims environment, or an equivalent combination of education and experience.
Proven experience in health claims processing, including Coordination of Benefits (COB), subrogation, and eligibility criteria understanding.
Knowledge of Medicaid and Medicare claims denial and appeals processes, along with a robust understanding of relevant regulatory guidelines.
Exceptional customer service experience.
Strong organizational skills to manage multiple projects effectively and meet deadlines.
Outstanding verbal and written communication skills.
Proficient in Microsoft Office Suite and relevant software applications.
Preferred Qualifications
Experience in customer or provider roles within managed care settings, medical offices, or hospitals.
Completion of healthcare-related vocational programs (e.g., certified coder, billing specialist, or medical assistant).
To apply for this exciting opportunity, please submit your application through our Internal Job Board if you are currently a Molina employee.
Molina Healthcare provides a competitive benefits and compensation package. We proudly uphold our commitment to being 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.