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ATTENTION JOB SEEKERS AND MOLINA APPLICANTS: FRAUD ALERT

Be aware that third parties posing as Molina Healthcare may be soliciting money from job seekers and extending offers to candidates who have not interviewed. Molina does not engage in these type of practices. If you have received an offer and have not been engaging with Molina Healthcare in an interview process, reach out to erc@molinahealthcare.com to validate the legitimacy of your offer. Please note that Molina has reported this activity to the appropriate law enforcement agencies for further investigation. If you feel you’ve been victimized, please report it to local law enforcement.

Specialist, Appeals & Grievances

Molina Healthcare Arizona; Roswell, New Mexico; Florida; Georgia; Buffalo, New York; Syracuse, New York; Wisconsin; Akron, Ohio; Vancouver, Washington; Kenosha, Wisconsin; Phoenix, Arizona; Tucson, Arizona; Mesa, Arizona; Atlanta, Georgia; Meridian, Idaho; Idaho Falls, Idaho; Warren, Michigan; Sterling Heights, Michigan; Ann Arbor, Michigan; Michigan; New York, New York; Houston, Texas; West Valley City, Utah; Madison, Wisconsin; Chandler, Arizona; St. Petersburg, Florida; Savannah, Georgia; Boise, Idaho; Des Moines, Iowa; Lincoln, Nebraska; Santa Fe, New Mexico; Columbus, Ohio; Washington; Cleveland, Ohio; Fort Worth, Texas; Spokane, Washington; Tacoma, Washington; Orlando, Florida; Davenport, Iowa; Lexington-Fayette, Kentucky; Covington, Kentucky; Kearney, Nebraska; Rio Rancho, New Mexico; Nebraska; New York; Dayton, Ohio; Layton, Utah; Green Bay, Wisconsin; Tampa, Florida; Augusta, Georgia; Caldwell, Idaho; Bowling Green, Kentucky; Owensboro, Kentucky; Idaho; Kentucky; New Mexico; Ohio; Texas; Austin, Texas; Salt Lake City, Utah; Bellevue, Washington; Racine, Wisconsin; Macon, Georgia; Sioux City, Iowa; Detroit, Michigan; Bellevue, Nebraska; Iowa; Rochester, New York; Utah; Cincinnati, Ohio; Provo, Utah; Seattle, Washington; Scottsdale, Arizona; Jacksonville, Florida; Cedar Rapids, Iowa; Iowa City, Iowa; Grand Rapids, Michigan; Omaha, Nebraska; Grand Island, Nebraska; Albuquerque, New Mexico; Yonkers, New York; Dallas, Texas; Columbus, Georgia; Nampa, Idaho; Las Cruces, New Mexico; San Antonio, Texas; Orem, Utah; Milwaukee, Wisconsin; Miami, Florida; Louisville, Kentucky Job ID 2029592
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JOB DESCRIPTION

Job Summary

Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

KNOWLEDGE/SKILLS/ABILITIES

  • Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.
  • Research claims appeals and grievances using support systems to determine appeal and grievance outcomes. 
  • 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 Healthcare guidelines.
  • Responsible for meeting production standards set by the department.
  • Apply contract language, benefits, and review of covered services
  • Responsible for contacting the member/provider through written and verbal communication.
  • Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
  • Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
  • Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
  • Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies

JOB QUALIFICATIONS

REQUIRED EDUCATION:

High School Diploma or equivalency

REQUIRED EXPERIENCE:

  • Min. 2 years operational managed care experience (call center, appeals or claims environment).
  • Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.
  • Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
  • Strong verbal and written communication skills

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full Time Posting Date: 01/08/2025

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