Specialist, Appeals & Grievances

Molina Healthcare • Rochester, NY • 2h 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

Senior Medical Director

Molina Healthcare • Rochester, NY • 2h ago

Hospital & Medical

JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - ensuring members receive the most app...

2h ago

Go to Apply

Farmworkers and Laborers

G & G Farms Inc. • Williamson, NY • 7h ago

Manufacturing & Warehouse

16 Fulltime H-2A Seasonal Jobs available 02/01/2026 - 11/30/2026. Manually plant, cultivate , and harvest apples & peaches . Use hand tools , such as shovels ,trowels ,hoes ,tampers , pruning hooks shears ,and knives...

7h ago

Go to Apply

AVP, Vendor Management - REMOTE

Molina Healthcare • Rochester, NY • 8h ago

Management & Administrative

JOB DESCRIPTION Job Summary Provides strategy and leadership to teams responsible for enterprise-wide vendor management activities - ensuring comprehensive operational efficiency, functional leadership engagement, sustai...

8h ago

Go to Apply

AI Solutions Engineering Delivery Lead

PwC • Rochester, NY • 8h ago

Retail & Hospitality

Specialty/Competency: IFS - Internal Firm Services - Other Industry/Sector: Not Applicable Time Type: Full time Travel Requirements: Up to 20% At PwC, our people in data and analytics engineering focus on leveraging adva...

8h ago

Go to Apply

Anesthesia Technician I

Rochester Regional Health • Rochester, NY • 8h ago

Hospital & Medical

Description Job Title: Anesthesia Technician IDepartment: Operating Room Location: Unity Hospital - 1555 Long Pond Rd Rochester, New York Hours Per Week: 40 hours per weekSchedule: Monday - Friday 2:00 PM - 10:30 PMSUMMA...

8h ago

Go to Apply

2025-26 Cleaner 21

Hilton Central School District • Hilton, NY • 8h ago

Must be able to meet requirements of 'Cleaner' job description. Must be able to follow oral and written instructions. The typical hours are between 3:00pm - 12:00am, Monday-Friday, 40hrs/week. Rotating weekends and occas...

8h ago

Go to Apply

Airport Security Guard - Afternoon Shift Available

Johnson Security Bureau, Inc. • Rochester, NY • 8h ago

Job Title: Airport Security Guard - Afternoon Shift Available Location: Frederick Douglass Greater Rochester International Airport (ROC) - Rochester, NY Company: Johnson Security Bureau, Inc. Employment Type: Full-Time P...

8h ago

Go to Apply

Facilities: Mechanic

Rochester Regional Health • Rochester, NY • 8h ago

Manufacturing & Warehouse

Description Job Title: Facilities: MechanicDepartment: Facilities Location: Rochester General Hospital - 1425 Portland Ave, Rochester, NY 14621Hours Per Week: 40 hoursSchedule: Monday to Friday, 4:00 PM - 12:30 AM, with...

8h ago

Go to Apply

Risk Manager/Senior Negotiator - State, Local & Higher Education

Deloitte • Rochester, NY • 11h ago

Management & Administrative

The Government & Public Services (GPS) Risk Management Team is currently seeking a full-time dedicated Senior Risk Manager/Senior Negotiator who has experience in supporting deal and contract structuring, drafting cu...

11h ago

Go to Apply

RESTAURANT SHIFT LEADER

Indus Hospitality Group • Hamlin, NY • 13h ago

Retail & Hospitality

RESTAURANT SHIFT LEADER Hamlin, NY ( http://maps.google.com/maps?q=1722+Lake+Road+Hamlin+NY+USA+14464 ) Job Type Part-time Description Summary Shift Leaders are generally responsible for coaching Restaurant Team Members...

13h 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.