Appeals and Grievances Specialist

Job Summary

To ensure compliance with regulatory standards, the full-time Appeals and Grievances Specialist will manage the research and resolution of member and provider complaints, appeals, and grievances while communicating outcomes effectively.

Key responsibilities

• Facilitates comprehensive research and resolution of appeals, disputes, grievances, and complaints from Molina members and providers
• Requests and reviews medical records and claims information to determine appropriate outcomes per regulatory guidelines
• Prepares appeal summaries and correspondence, documenting findings and trends as needed

Required qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment
• Health claims processing experience, including coordination of benefits and eligibility criteria
• Experience with Medicaid and Medicare claims denials and appeals processing
• Strong organizational and time management skills to manage multiple projects
• Proficiency in Microsoft Office suite and applicable software programs