Specialist, Appeals & Grievances
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Before you apply
SalaryNo pay range posted
LocationBothell, WA, United States
SeniorityMid
Experience2+ yrs
Company size10,000+ people
First seenOct 17, 2026 · 2w ago
Verified live20h ago
At a glanceSummarised by Seekless from the posting.
At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience
Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria
Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials
Customer service experience
Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines
Effective verbal and written communication skills
Microsoft Office suite/applicable software program(s) proficiency
Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting
Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant)
Billing Experience
Skills
Microsoft Office suite
Specialist, Appeals & Grievances
Job Summary
Provides 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
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Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met.
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Researches claims appeals and grievances using support systems to determine appropriate appeals and grievance outcomes.
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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.
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Meets claims production standards set by the department.
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Applies contract language, benefits and review of covered services to claims review process.
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Contacts members/providers as needed via written and verbal communications.
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Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested).
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Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements.
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Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.
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Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies.
Required Qualifications
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At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
•
Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria.
•
Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
•
Customer service experience.
•
Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
•
Effective verbal and written communication skills.
•
Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting.
Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).
Billing Experience
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.
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