JOB DESCRIPTION Job Summary
Provides support for pre service appeals for members across all states throughout the organization, communicating with members and providers in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).
Essential Job Duties
• 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.
• Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines.
• Meets claims production standards set by the department.
• Applies contract language, benefits and review of covered services to claims review process.
• Contacts members/providers as needed via written and verbal communications.
• Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested).
• Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements.
• Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.
• 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
• 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
• Experience with appeals for Medicare and Medicaid and the regulations with CMS.
• Experience with pre authorization appeals.
• Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).
• Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting.
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.
Skills Required
- At least 2 years of managed care experience in a call center, appeals, claims environment, or equivalent education and experience
- Health claims processing experience, including coordination of benefits, subrogation, and eligibility criteria
- Experience with Medicaid and Medicare claims denials and appeals processing
- 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 or applicable software proficiency
- Experience with Medicare and Medicaid appeals and CMS regulations
- Experience with preauthorization appeals
- Completion of a healthcare-related vocational program, such as certified coding, billing, or medical assisting
- Customer or provider experience in a managed care organization or medical office/hospital setting
Molina Healthcare Inc. Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Molina Healthcare Inc. and has not been reviewed or approved by Molina Healthcare Inc..
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Healthcare Strength — Health coverage is described as solid, including medical, dental, and vision insurance alongside options like HSA/FSA and disability coverage. Benefits are often seen as a meaningful part of the overall package.
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Retirement Support — A 401(k) with employer matching and an ESPP are offered, and the retirement plan is commonly regarded as a plus. These features help round out compensation even when base pay is seen as only acceptable.
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Leave & Time Off Breadth — PTO, paid holidays, and paid parental leave are part of the offering, with time‑off benefits generally viewed favorably. Backup family care and an employee assistance program add practical support.
Molina Healthcare Inc. Insights
What We Do
Molina Healthcare Inc. is dedicated to delivering effective, reliable, and affordable health care to those who need it most. The company focuses on improving the health and well-being of its members and positively impacting the communities it serves. Recognized as a leader in the health insurance category, it provides essential healthcare services to ensure accessible and quality care for its members.
