Specialist, Appeals & Grievances

Molina Healthcare • Saint Petersburg, FL • 1d ago

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

REQU IRED ED UC ATI ON :

High School Diploma or equivalency

REQU IRED E XPE RI EN CE:

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.

Similar Jobs

Marketing Manager Lead

USAA • Tampa, FL • 20min ago

Management & Administrative

Why USAA? At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the #1 choice for the military community a...

20min ago

Go to Apply

Senior Digital Electrical Engineer (ONSITE)

RTX Corporation • Largo, FL • 1h ago

IT & Engineering

Date Posted: 2025-10-27 Country: United States of America Location: FL410: Largo FL MFG 7887 Bryan Dairy Road , Largo, FL, 33777 USA Position Role Type: Onsite U.S. Citizen, U.S. Person, or Immigration Status Requirement...

1h ago

Go to Apply

Principal Digital Electrical Engineer (ONSITE)

RTX Corporation • Largo, FL • 1h ago

IT & Engineering

1h ago

Go to Apply

Advanced Lead Engineer - Project Management

GE Aerospace • Clearwater, FL • 2h ago

Management & Administrative

Job Description Summary The Civil Platforms (CP) Team is seeking an Engineering Project Manager (EPM) to lead the Integrated Modular Avionics (IMA) and Platform Systems projects. The EPM will be responsible for driving e...

2h ago

Go to Apply

Agentic DevOps Engineer

Accenture • Saint Petersburg, FL • 2h ago

IT & Engineering

We Are The beginning of a new Data & AI decade that will reshape work and society has begun. Accenture is stepping boldly into this future with a clear strategy and purpose: to help clients optimize and reinvent thei...

2h ago

Go to Apply

CONSTRUCTION SENIOR PROJECT MANAGER - 55004265

MyFlorida • Tampa, FL • 5h ago

Trucking & Construction

CONSTRUCTION SENIOR PROJECT MANAGER - 55004265 Date: Oct 27, 2025 The State Personnel System is an E-Verify employer. For more information click on our E-Verify Website ( http://www.dms.myflorida.com/workforce\operations...

5h ago

Go to Apply

General & Product Liability Complex Claim Examiner - Multi-State Preferred - Hybrid - Sedgwick Office

Sedgwick • Tampa, FL • 5h ago

Management & Administrative

By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experi...

5h ago

Go to Apply

Driver / Warehouse

Consolidated Electrical Distributors • Tampa, FL • 6h ago

Manufacturing & Warehouse

Summary Job title: Driver / Warehouse Job ID: null Department: Tampa - RAY Location: null-null Description Summary: The driver / warehouse position is responsible for maintaining a professional appearance and knowledge o...

6h ago

Go to Apply

Licensed Practical Nurse Home Health

CenterWell • Tampa, FL • 6h ago

Hospital & Medical

Become a part of our caring community and help us put health first Make a meaningful impact every day as a CenterWell Home Health nurse. You'll provide personalized, one-on-one care that helps patients regain independenc...

6h ago

Go to Apply

Hotel Housekeeping Room Attendant

Atrium Hospitality • Tampa, FL • 8h ago

Retail & Hospitality

Hotel : Tampa Embassy Suites 3705 Spectrum Blvd Tampa, FL 33612 Full time Compensation Range : $14.70 - $15.00 Compensation is determined based on a variety of factors, including experience, skills, qualifications, and t...

8h ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.