Specialist in Appeals and Grievances with Medicaid/...

Job Summary Become a key member of our exceptional team as a Specialist in Appeals and Grievances. In this important role, you'll ensure outstanding service for our members and providers while expertly navigating the complexities of claims activities. Your focus will be on resolving issues and communicating outcomes in compliance with the standards established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties Engage in thorough research and resolution of appeals, grievances, and complaints from Molina members and providers, while adhering to internal and regulatory timelines. Leverage support systems to effectively analyze claims appeals and determine appropriate outcomes. Request and assess medical records and billing information to formulate responses in line with protocols, collaborating with other business partners as required. Consistently achieve claims production standards set by the department. Review contract language and benefits to ensure compliance with claims processing procedures. Maintain clear communication with members and providers through proficient written and verbal interactions. Prepare detailed appeal summaries and documentation, including necessary data trends. Draft correspondence and dispute documentation that strictly adheres to regulatory guidelines. Investigate claims processing standards and provider contracts to pinpoint root causes of payment discrepancies. Respond to incoming provider reconsideration requests for claims adjustments and interact with external agencies. Required Qualifications At least 2 years of experience in managed care, particularly in call centers, appeals, or claims roles, or a related educational background. In-depth knowledge and practical experience in health claims processing, including coordination of benefits (COB) and eligibility parameters. Understanding of Medicaid and Medicare claims denials and appeal processes, as well as related regulatory guidelines. Strong customer service skills and experience. Exceptional organizational and time management abilities, with a knack for managing various projects to meet deadlines. Excellent verbal and written communication capabilities. Proficient in Microsoft Office suite and other relevant software tools. Preferred Qualifications Direct experience with customers/providers in a managed care environment, 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 offers 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.

Created: 2026-03-11