Lead Specialist, Appeals & Grievances

JOB DESCRIPTION Job Summary Provides lead 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 Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. u2022 Trains new employees and provides guidance to others with respect to complex appeals and grievances. u2022 Researches and resolves escalated issues including state complaints and high visible complex cases. u2022 In conjunction with claims leadership, assigns claims work to team. u2022 Prepares appeal summaries and correspondence, and documents information for tracking/trending data. u2022 Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. u2022 Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. u2022 Meets claims production standards set by the department. u2022 Applies contract language, benefits, and review of covered services. u2022 Contacts members/providers via written and verbal communications as needed. u2022 Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. u2022 Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. u2022 Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. u2022 Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies. Required Qualifications u2022 At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. u2022 Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria. u2022 Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. u2022 Strong customer service experience. u2022 Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. u2022 Strong 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. u2022 Completion of a health care related vocational program in health care (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: $21.65 - $46.42 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2026-01-19