**JOB DESCRIPTION** **Job Summary** Responsible for reviewing and resolving member & 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. **KNOWLEDGE/SKILLS/ABILITIES** + Enters denials and requests for appeal into information system and prepares documentation for further review. + Research issues utilizing systems and other available resources. + Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines. + Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research. + Determines appropriate language for letters and prepare responses to appeals and grievances. + Elevates appropriate appeals to the Appeals Specialist. + Generates and mails denial letters. + Assists with interdepartmental issues to help coordinate problem solving in an efficient and timely manner. + Creates and/or maintains statistics and reporting. + Works with provider & member services to resolve balance bill issues and other member/provider complaints. **JOB QUALIFICATIONS** **REQU** **I** **RED ED** **U** **C** **A** **TI** **O** **N** **:** High School Diploma or equivalency **REQU** **I** **RED E** **X** **PE** **R** **I** **E** **N** **C** **E:** + 1 year of Molina experience, health claims experience, OR one year of customer service/provider service experience in a managed care or healthcare environment. + 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 - $34.88 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.