Director of Appeals and Grievances (REMOTE) at Molina Healthcare

Molina Healthcare Job ID 2006424

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Job Description
Job Summary
This role will have a heavy focus on leading our reporting and analytics in A&G. Responsibilities include leading an audit and analytics team, managing/improving quality reporting, analyzing trends and ad hoc reporting. Ideal candidates would have experience in Appeals & Grievances, Medicaid reporting and analytics and reporting.

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.


  • Reviews and analyzes collective grievance and appeals data along with audit results on unit’s performance; analyzes and interprets trends and prepares reports that identify root causes of member/provider dissatisfaction
  • Recommends and implements process improvements to achieve member/provider satisfaction of operational effectiveness/efficiencies.
  • Leads, organizes, and directs the activities of the Appeals & Grievance unit that is responsible for member and provider Appeals and Grievances for Marketplace. 
  • Provides direct oversight, monitoring and training of provider dispute and appeals units to ensure adherence with Marketplace standards and requirements.
  • Trains grievance and appeals staff and other departments within Molina Marketplace on early recognition an timely routing of member complaints
  • Trains provider dispute resolution unit on Marketplace standards and requirements, including the proper use of the Molina Appeals and Grievance system.

Job Qualifications

  • Strong claims background
  • Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
  • Management of 100+ employee’s experience.
  • 7 years’ experience in healthcare claims review and/or member appeals and grievance processing/resolution, including 2 years in a manager role.
  • Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, 2 years supervisory/management experience with appeals/grievance processing within a managed care setting.

Required Education
Associate’s Degree or 4 years of grievance and appeals experience.

Required License, Certification, Association


Preferred Education
Bachelor’s Degree

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.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full Time Posting Date: 01/11/2021


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