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Job Description Job Summary Responsible for leading, organizing, and directing the activities of the Grievance and Appeals Unit. This unit reviews and resolves member complaints and communicates resolutions to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. Knowledge/Skills/Abilities Leads, organizes, and directs the activities of the Appeals & Grievances unit responsible for reviewing and resolving member complaints and communicating resolutions in line with Centers for Medicare and Medicaid standards/requirements. Provides oversight, monitoring, and training to local plans' provider dispute and appeals units to ensure compliance with Medicare standards related to non-contracted provider dispute/appeals processing. Establishes and updates member and non-contracted provider grievance/dispute and appeals policies/procedures annually or as directed by CMS. Trains grievance and appeals staff, customer/member services, sales, UM, and other departments on early recognition and timely routing of member complaints. Trains each state's provider dispute resolution unit on CMS standards, including proper use of the Molina Provider Grievance and Appeals system. Reviews and analyzes grievance and appeals data, audit results, and trends; prepares reports identifying root causes of member dissatisfaction; and recommends process improvements to enhance member/provider satisfaction and operational efficiency, contributing to Molina Medicare's STAR ratings. Job Qualifications Required Education Associate's degree or 4 years of Medicare grievance and appeals experience. Required Experience 7 years' experience in healthcare claims review and/or provider appeals and grievance processing/resolution, including 2 years in a managerial role. Experience reviewing all types of medical claims (e.g., CMS 1500, outpatient/inpatient, universal claims, surgery, anesthesia, high-dollar complex claims, COB, and DRG/RCC pricing), and IPA. 2 years supervisory/management experience with appeals/grievance processing within a managed care setting. Preferred Education Bachelor's degree. Previous Director experience. IPA support experience. To current Molina employees interested in applying: please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V.

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