Associate Specialist, Appeals & Grievances (Provider ...

JOB DESCRIPTION Job Summary Provides entry level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Essential Job Duties u2022 Enters denials and requests for appeals into information system and prepares documentation for further review. u2022 Researches claims issues utilizing systems and other available resources. u2022 Assures timeliness and appropriateness of appeals according to state, federal and Molina guidelines. u2022 Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research. u2022 Determines appropriate language for letters and prepares responses to member appeals and grievances. u2022 Elevates appropriate appeals to the next level for review. u2022 Generates and mails denial letters. u2022 Provides support for interdepartmental issues to help coordinate problem-solving in an efficient and timely manner. u2022 Creates and/or maintains appeals and grievances related statistics and reporting. u2022 Collaborates with provider and member services to resolve balance bill issues and other member/provider complaints. Required Qualifications u2022 At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting, or equivalent combination of relevant education and experience. u2022 Customer service experience. u2022 Organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. u2022 Effective verbal and written communication skills. u2022 Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications u2022 Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting experience. u2022 Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.16 - $34.88 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-12-05