Specialist, Appeals & Grievances

JOB DESCRIPTION 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

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.