Molina Healthcare jobs in New York, NY - 175 jobs

Leads and supervises a team of pharmacy call center representatives and operations staff responsible to ensure that members have access to medically necessary prescription drugs. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Essential Job Duties * Hires, trains, develops, and supervises a team of pharmacy service representatives supporting processes involved with Medicare Stars and Pharmacy quality operations. * Ensures that average phone call handle time, average speed to answer, and average hold time are compliant with Centers for Medicare and Medicaid Services (CMS) regulations. * Ensures that adequate staffing coverage is present at all times of operation. * Assists pharmacy leadership with monitoring and oversight of Molina's contracted Pharmacy Benefit Manager (PBM) for pharmacy contractually delegated functions. * Responsible for key performance indicators (KPI) reporting to department leadership on a monthly basis. * Participates, researches, and validates materials for both internal and external program audits. * Acts as liaison to internal and external customers to ensure prompt resolution of identified issues. * Assists pharmacy leadership in the collection and tabulation of data for reporting purposes and maintains files of confidential information submitted for review. * Assures that activities and processes are compliant with CMS, National Committee of Quality Assurance (NCQA) guidelines, and Molina policies and procedures. * Participates in the daily workload of the department, performing Representative duties as needed. * Facilitates interviews with pharmacy service representative job applicants, and provides hiring recommendations to leadership. * Provides coaching for pharmacy representatives, and helps identify and provide for training needs in collaboration with pharmacy leadership. * Communicates effectively with practitioners and pharmacists. * Collaborates with and keeps pharmacy leadership apprised of operational issues, including staffing resources, program and system needs. * Assists with development of and maintenance of pharmacy policies and procedures * Participates in the development of programs designed to enhance preferential or required targeted drugs or supplies. Required Qualifications * At least 5 years of experience in health care, preferably within a health-related call center environment, or equivalent combination of relevant education and experience. * Knowledge of prescription drug products, dosage forms and usage. * Experience designing, implementing, monitoring, and evaluating metrics that measure call center agent productivity. * Working knowledge of medical/pharmacy terminology * Excellent verbal and written communication skills. * Microsoft Office suite, and applicable software program(s) proficiency. Preferred Qualifications * Supervisory/leadership experience. * Certified Pharmacy Technician (CPhT) and/or state pharmacy technician license (state specific if state required). If licensed, license must be active and unrestricted in state of practice. * Call center experience. * Managed care experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $55,706.51 - $80,464.96 / ANNUAL * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. 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.

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. **Must be willing to travel to NYC twice a year for required meetings.** **Position Purpose:** The focus of this position is to establish processes to respond to ICD-10 coding changes and its effect on inpatient claims payment. Chart review will include DRG pre-payment review, hospital readmission review and outlier payment review. + Analyze moderately complex health care information; reviews medical records; integrate medical coding and reimbursement rules; provide pricing guidance. + Ensure medical coding rules and regulations including compliance requirements are adhered to for the appropriate handling of medical necessity, claims denials, and bundling issues. + Provide regular reports on project status and progress; report project results to identify coding improvement opportunities. + Collaborate with other business units to identify and implement process efficiency and quality improvement practices. + Work with IT resources to implement system efficiencies and configuration enhancements to improve claims processing operations. + Apply Coding Guidelines as described in the ICD-10 Coding Manual. + Performs other duties as assigned. + Complies with all policies and standards. **Education/Experience:** RN Degree. One year experience preferred in hospital inpatient coding. Nursing experience in managed care organization or acute care hospital. One year of experience in a clinical setting or acute care hospital; RN, PA, MD, APRN, DO or MBBS license required. **Coding Credential Required:** Valid/Current CPC Certification, through APPC preferred or CIC through AAPC or CCS through AHIMA; RHIA/RHIT Credentials-Preferred. Pay Range: $68,700.00 - $123,700.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Assesses, plans, and implements complex care management activities based on member activities to enable quality, cost-effective healthcare outcomes. Develops a personalized care plan / service plan for care members, addresses issues, and educates members and their families/care givers on services and benefit options available to receive appropriate high-quality care. + Develops and continuously assesses ongoing care plans / service plans and collaborates with providers to identify providers, specialist, and/or community resources needed to address member's unmet needs + Coordinates and manages as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services + Monitors care plans / service plans and/or member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs + May identify problems/barriers for care management and appropriate care management interventions for escalated cases + Reviews member data to identify trends and improve operating performance and quality care in accordance with state and federal regulations + Reviews referrals information and intake assessments to develop appropriate care plans/service plans + May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources + Collaborates with healthcare providers as appropriate to facilitate member services and/or treatments and determine a revised care plan for member if needed + Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators + Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits + Partners with leadership team to improve and enhance care and quality delivery for members in a cost-effective manner + May precept clinical new hires by fostering and building core skills, coaching and facilitating their growth, and guiding through the onboarding process to upskill readiness + Provides guidance and support to clinical new hires/preceptees in navigating within a Managed Care Organization (MCO) and provides coaching and shadowing opportunities to bridge gap between classroom training and field practice + Engages and assists New Hire/Preceptee during onboarding journey including responsibility for completing competency check points ensuring readiness for Service Coordination success + Engages in a collaborative and ongoing process with People Leaders and cross functional teams to measure and monitor readiness + Other duties or responsibilities as assigned by people leader to meet business needs + Performs other duties as assigned + Complies with all policies and standards **Education/Experience:** Requires a Degree from an Accredited School or Nursing or a Bachelor's degree in Nursing and 4 - 6 years of related experience. **License/Certification:** + RN - Registered Nurse - State Licensure and/or Compact State Licensure required Pay Range: $75,300.00 - $135,400.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Responsible for developing, conducting, administering, and analyzing clinical coding training and auditing programs. The Senior Clinical Coding Auditor & Trainer will conduct audits of inpatient coding processes for Fidelis Care and assist in development of training and audit tools. ***The Senior Clinical Coding Auditor & Trainer position is primarily remote with a small travel expectation on an annual basis. Candidates must be willing to travel to New York twice a year to be considered for the position. *** **Responsibilities:** + Develop and maintain complex audit processes and audit tools related to inpatient coding + Develop and conduct clinical education courses for existing and new employees + Audit established guidelines for medical necessity + Analyze training needs and identify, select, or develop appropriate training programs including training aids and materials + Audit staff in accordance with established auditing processes, work with staff to identify and resolve errors, and present findings and recommendations for improvement to management + Evaluate effectiveness of training programs + Research, analyze, and recommend internal/external training programs + Maintain records of training activities and employee progress + Assist with revisions to Policy and Procedure and/or work process development for inpatient coding + Travel may be required **Highly Preferred Skills:** + Inpatient Coding Experience (valid/current CPC, CIC, or CCS Certification) + At least 1 year of clinical experience in a hospital setting + Nursing license required + Strong written English communication skills **Education/Experience:** Bachelor's degree in Nursing, related clinical field or equivalent experience. 4+ years of experience in nursing, training, or auditing in a managed care healthcare setting. Experience in a lead or supervisory role preferred. **License/Certification:** Current state nursing license. Driver's license may be required for certain positions. Pay Range: $68,700.00 - $123,700.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Become a part of our caring community and help us put health first As a Senior Data Engineer, you will play a critical role in building the Agentic AI platform and delivering cutting-edge AI-powered solutions. You'll work with large-scale datasets and state-of-the-art tools to address complex business problems. This role involves close collaboration with data scientists and fellow engineers across the entire AI development lifecycle-from data ingestion to deployment and monitoring. * Explore and implement generative AI technologies using Large Language Models and other generative models to create innovative solutions. * Build and maintain robust APIs for enabling Retrieval-Augmented Generation and generative AI agents within business use cases. * Design, develop, and maintain robust data pipelines for ingestion, processing, and transformation of large datasets. * Assist our data science team in the development and deployment of traditional machine learning models. * Collaborate with data scientists to understand model requirements and translate them into scalable engineering solutions. * Monitor and maintain performance and reliability of deployed APIs, models, and data pipelines. * Stay up to date with the latest advancements in machine learning, generative AI, and related technologies. Use your skills to make an impact Required Qualifications: * Bachelor's Degree in a quantitative discipline (e.g., Computer Science, Mathematics, Statistics, or a related field) with a minimum of 5 years of professional experience; OR * 7+ years of Python application development and data manipulation libraries (e.g., Pandas, NumPy). * Familiarity with API frameworks (e.g., FastAPI, Flask) and RESTful API concepts. * 3+ years of experience with containerization (e.g., Docker, Kubernetes). * 3+ years of experience with CI/CD tools, pipelines * 3+ years of experience with PySpark. * 2+ years of experience working on any cloud platform. (Azure / GCP / AWS) * Strong understanding of machine learning frameworks (e.g., TensorFlow, PyTorch, Scikit-learn). * Knowledge of generative AI frameworks such as Langchain or Pydantic AI. * Experience working with Large Language Model (LLM) in application development Highly Desired Qualifications: * Master's Degree in a similar field with at least 5 years of relevant experience. * Experience with version control systems (e.g., Git) and software development best practices. * Excellent problem-solving skills and ability to work in a collaborative environment. * Experience deploying software using tools like Docker and Kubernetes. * Experience with deep learning techniques and frameworks. * Experience working with any nosql DBs. * Knowledge of natural language processing (NLP). * Familiarity with big data and data streaming technologies (e.g., Hadoop, Spark, kafka). This is a HYBRID office position requiring an in-office presence 3 days/wk in one of the following locations: Dallas, TX, Tampa, FL, Washington DC, Boston, MA, NYC, New York, or Louisville, KY. You must reside within commutable distance or be willing to relocate to our offices located in these areas. Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $117,600 - $161,700 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. About Us Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Provides support for coordination of benefits review activities that directly impact medical expenses and premium reimbursement. Responsible for primarily coordinating benefits with other carriers responsible for payment. Facilitates administrative support, data entry, and accurate maintenance of other insurance records. Job Duties * Provides telephone, administrative and data entry support for the coordination of benefits (COB) team. * Phones or utilizes other insurance company portals to validate state, vendor, and internal COB leads. * Updates the other insurance table on the claims transactional system and COB tracking database. * Review of claims identified for overpayment recovery. Job Qualifications REQUIRED QUALIFICATIONS: * At least 1 year of administrative support experience, or equivalent combination of relevant education and experience. * Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Strong verbal and written communication skills. * Ability to work cross-collaboratively across a highly matrixed organization and establish and maintain effective relationships with internal and external stakeholders. * Microsoft Office suite proficiency. PREFERRED QUALIFICATIONS: * Health care experience To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $31.71 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. 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.

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT. Position Purpose: The Field Retention Representative is responsible for retaining current membership in an assigned territory and must meet the daily production metrics designed to achieve higher membership retention. The Field Retention Representative conducts telephonic and field outreach which includes assistance at community events, provider and community office sites and home visits to new and existing members and must be able to effectively explain, communicate, and assist with all Fidelis Care products. It is the responsibility of the Retention Field Representative to ensure compliance with all regulatory, audit and corporate policies. Field position working within Nassau County Long Island, NY. Bilingual in Spanish, Mandarin, Cantonese, Hindi or Urdu strongly preferred. Provide member resolution by researching, analyzing and documenting inquiries regarding program eligibility Answer application and/or service questions regarding the programs and services in order to maintain/attract membership Conduct outreach and follow up calls to educate members about Fidelis Products and serves as a liaison between the member and the different Fidelis departments Ability to meet and exceed quality assurance standards Ability to undergo rigorous internal training and have complete command of the sales process, all Fidelis Care products, competitive environment in their region successfully pass test(s) as required(with a minimum 85% score)with no more than 2 attempts, that will demonstrate a level of proficiency Have the ability to conduct a needs based analysis to better understand the best course of action based on those needs and be able to answer product feature and benefit questions and provider network questions for members both within and outside of their region Develop and maintain relationships with existing members by providing guidance and assistance throughout the year Demonstrate passion for members by identifying unfulfilled needs and providing necessary education and assistance to promote the value and benefits offered by Fidelis Care Modify delivery skills accordingly to overcome objections and retain members Identify solutions to issues and concerns Document all interactions in the appropriate system (Sales Force, Facets) including marketing leads Track and input interaction taken as a result of each communication in order to ensure all member accounts correctly reflect activities performed Input, update and create member information on databases in order to maintain customer accounts Utilize computer systems to perform administrative functions such as Sales Force Job performance requires fulfilling other incidental or related duties as assigned, assisting and training others, and performing duties of higher rated positions from time to time for developmental purposes Performs other duties as assigned Complies with all policies and standards Education/Experience: High School Diploma, or GED, required. Associates Degree or Bachelors Degree preferred. Minimum 1 year health care related experience preferred. Minimum 1 year of customer service or sales experience preferred. Driver's License required. Specific language skills may be required by some plans. Sales experience highly preferred. Bilingual in Spanish, Mandarin, Cantonese, Hindi or Urdu strongly preferred. Pay Range: $23.23 - $39.61 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. **Location: Position in hybrid and will include field visits. Candidate must reside in New York. Prefer candidate to live in/around Upstate New York.** ***Full time position includes 37.5 hours** **Position Purpose:** The Community Quality Liaison serves as a vital link between members and the healthcare system, focusing on improving health outcomes by identifying and closing care gaps. This role emphasizes community engagement, member education, and collaboration with providers and internal teams to ensure members receive timely, appropriate care and support. + Conduct outreach to members in the community to identify care gaps and connect them with appropriate healthcare services and resources. + Perform home visits or community-based assessments to evaluate member needs and identify social determinants of health that may prevent members from accessing preventive or follow-up care, and facilitate care coordination. + Serve as a member advocate by helping individuals navigate complex healthcare and social service systems. Assist with scheduling appointments, understanding care plans, and accessing benefits or entitlements, ensuring members receive the support needed to close care gaps and maintain continuity of care + Collaborate with providers to share quality performance data (e.g., HEDIS, CAHPS) and support improvement initiatives. + Educate members on preventive care, chronic condition management, and available community resources. + Document member interactions, care gap closures, and referrals in the appropriate systems. + Partner with internal departments (e.g., Quality, Care Management, Provider Relations) to align efforts and improve member outcomes. + Monitor and report on outreach effectiveness and care gap closure metrics. + Maintain compliance with state and federal regulations and organizational policies. + Participate in seasonal campaigns and quality initiatives to improve member engagement and health outcomes. + Serve as a community ambassador, building relationships with local organizations and stakeholders. + Performs other duties as assigned. + Complies with all policies and standards. **Education/Experience:** Bachelor's Degree Social Work, Public Health, Nursing, or related field; or equivalent experience required 2+ years In community health or healthcare quality required Experience working with health plan members and navigating community resources required Familiarity with Medicaid / Medicare programs and quality measures (e.g., HEDIS) required Strong communication and interpersonal skills **Licenses/Certifications:** LCSW- License Clinical Social Worker preferred **Location: Position in hybrid and will include field visits. Candidate must reside in New York. Prefer candidate to live in/around Upstate New York.** Pay Range: $27.02 - $48.55 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as an Intern at Centene. During this 12-week program, you'll learn more about Centene and how we're transforming the health of the community, one person at a time. Observe preceptors and participate in various projects to learn and develop skills related to the Managed Care industry. + Develop clinical knowledge and skills by learning about various processes and functions within the Managed Care industry + Observe processes and shadow preceptors to gain hands on experience and become familiar with various clinical services + Follow instructions and procedures provided by preceptor or manager in accordance with company guidelines **Education/Experience:** Current enrollment in an accredited clinical program. Candidates must be receiving course credit for participating in the Externship program. Centene offers a comprehensive benefits package including competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field, or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. **We're Hiring: Full time Medical Directors in New York!** Centene Corporation is a leading provider of government-sponsored healthcare coverage, providing access to affordable, high-quality services to Medicaid and Medicare members, as well as to individuals and families served by the Health Insurance Marketplace. Looking for a compelling opportunity to move beyond patient encounters and drive meaningful change in the community? **Qualifications for this role include:** + MD or DO without restrictions + Must be licensed in New York + Board certified in Internal Medicine or Family Medicine preferred + Utilization Management experience and knowledge of quality accreditation standards. + Actively practices medicine **Position Purpose:** Assist the Chief Medical Director to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit. + Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities. + Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making. + Supports effective implementation of performance improvement initiatives for capitated providers. + Assists Chief Medical Director in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members. + Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements. + Assists the Chief Medical Director in the functioning of the physician committees including committee structure, processes, and membership. + Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes. + Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals. + Participates in provider network development and new market expansion as appropriate. + Assists in the development and implementation of physician education with respect to clinical issues and policies. + Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components. + Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care. + Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality. + Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment. + Develops alliances with the provider community through the development and implementation of the medical management programs. + As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues. + Represents the business unit at appropriate state committees and other ad hoc committees. + May be required to work weekends and holidays in support of business operations, as needed. + Performs other duties as assigned + Complies with all policies and standards **Education/Experience:** Medical Doctor or Doctor of Osteopathy. Utilization Management experience and knowledge of quality accreditation standards preferred. Actively practices medicine. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is advantageous. Experience treating or managing care for a culturally diverse population preferred. **License/Certifications:** Board certification in a medical specialty recognized by the American Board of Medical Specialists or the American Osteopathic Association's Department of Certifying Board Services. (Certification in Psychiatry specialty Is required.) **Current New York state license** as a MD or DO without restrictions, limitations, or sanctions from government programs. Pay Range: $231,900.00 - $440,500.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. ESSENTIAL JOB DUTIES: Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Provides entry level 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 * Enters denials and requests for appeals into information system and prepares documentation for further review. * Researches claims issues utilizing systems and other available resources. * Assures timeliness and appropriateness of appeals according to state, federal and Molina guidelines. * Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research. * Determines appropriate language for letters and prepares responses to member appeals and grievances. * Elevates appropriate appeals to the next level for review. * Generates and mails denial letters. * Provides support for interdepartmental issues to help coordinate problem-solving in an efficient and timely manner. * Creates and/or maintains appeals and grievances related statistics and reporting. * Collaborates with provider and member services to resolve balance bill issues and other member/provider complaints. Required Qualifications * At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting, or equivalent combination of relevant education and experience. * Customer service experience. * Organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. * Effective verbal and written communication skills. * Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications * Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting experience. * Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $34.88 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. 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.

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. **Position Purpose:** Lead Business Process Consultant provides management support and strategic guidance and expertise to business case development for enterprise level initiatives across many functional areas and leads larger scale, complex, cross-functional initiatives. Drives strategic recommendations for portfolio planning with an emphasis on proactive solutions. Involved in team level development activities, such as training, mentoring, and tracking department metrics. + Mentors junior team members on duties and responsibilities with supervision from leadership. Leads all levels of staff who are responsible for initiatives included in the companies operating plan in order to support their success, development and effective completion and communication of their initiative + Oversee the pipeline of business cases and prioritize them based on strategic value, interdependencies, risk appetite, and available capacity. + Ensure consistent methodology and rigor in business case development across all teams, providing quality assurance and coaching to Senior Business Process Consultants. Ensures that all approved business cases are transitioned to initiatives (both documentation and clear responsibilities for each initiative) and tracks ROI for launched projects and initiatives. + Leads engagement and communications with senior and executive stakeholders, translating business pain points into strategic recommendations and ensures successful execution towards plan. + Coordinates proactive collaboration across cross-functional teams to identify and proactively respond to stakeholder business problems. + Leads larger scale, cross-functional initiatives that are intended to drive performance improvement, financial gains, customer satisfaction and improved compliance. + Provides strategic and policy guidance on assigned initiatives so that all processes are considered for maximizing effective implementation and results. + Organizes work teams, drives consensus and ensures end to end policy/process integrity to accomplish project work: including identification and confirmation of participants, consistent work team engagement and productivity, meeting facilitation, consensus building, recommendation documentation and implementation oversight. + Assists functional and project leaders in areas as needed such as facilitation, analysis, process mapping, brain-storming, project management issues, etc. + Writes and delivers communication to all levels of organization to ensure support, awareness and effectiveness of process improvement initiatives. + Provides other related support as needed to improve the performance of the business. + Performs other duties as assigned. + Complies with all policies and standards. **Education/Experience:** Bachelor's Degree in a related field or equivalent experience required Master's Degree in a related field preferred 7+ years experience managing, leading projects within a consulting, healthcare, and or related sectors required **Licenses/Certifications:** Certified Project Management Professional (PMP)-PMI preferred Process quality certification preferred Pay Range: $107,700.00 - $199,300.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Centene is transforming the health of our communities one person at a time. As an Executive on our team, you could be the one who changes everything for our 28 million members. Oversee operations for multiple support functions, including configuration, claims support services, provider relations, call center and field operations. + Perform duties as chief liaison between the business unit and Corporate policies & standards. + Develop operational vision, objectives and policies and procedures to support the overall strategic plan for the business unit. + Ensure cost effective, client-responsive programs are developed and maintained, identify improvement opportunities and oversee successful implementation of those changes throughout shared services. + Identify operational efficiencies, meet regulatory and client expectations and develop a "best practice" approach for all operations. + Responsible for achieving business unit financial targets and requirements based on service level, state, compliance and contractual agreements. + Oversee new system and product implementations for assigned areas. + Assess organizational strengths and weaknesses to recommend enhanced operating model. **Education/Experience:** Bachelor's Degree in Business Administration, Healthcare Administration or related field required. Master's Degree preferred. 10+ years in Business Administration, Healthcare Administration or related field required. Must reside in and/or relocate to NYC area. Pay Range: $280,000.00 - $490,000.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

JOB DESCRIPTION Job SummaryProvides support for medical records collection activities. Supports quality improvement activities through outreach to providers for collection of medical records for Healthcare Effectiveness Data and Information Set (HEDIS) specific data collection, projects and audit processes. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties * Outreaches to providers via phone call, fax, mail, electronic medical record system retrieval and direct on-site pick up for collection of medical records. * Loads medical records and reports from provider offices into the Healthcare Effectiveness Data and Information Set (HEDIS) application. * Supports annual HEDIS audit and other like audits, and organizes provider outreach, pursuit, collection and upload of provider medical records into the internal database. * Provides project management support to leadership via coordination, identification, pursuit and collection of medical records and other required data with other HEDIS staff. * Participates in meetings with vendors related to the medical record collection process. * Some medical records collection related travel may be required. Required Qualifications• At least 1 year customer service experience, preferably in an administrative support capacity in a health care setting, or equivalent combination of relevant education and experience. * Valid and unrestricted driver's license, reliable transportation, and adequate auto insurance for job related travel requirements. * Excellent customer service and active listening skills. * Proficiency with data analysis tools (e.g., Excel). * Ability to manage files, schedules and information efficiently. * Ability to effectively interface with staff, clinicians, and leadership. * Strong prioritization skills and detail orientation. * Strong verbal and written communication skills, including professional phone etiquette. * Microsoft Office suite/applicable software program(s) proficiency, and ability to learn new programs. Preferred Qualifications * Registered Health Information Technician (RHIT). * Medical records collection experience. * Managed care experience. * Basic knowledge of Healthcare Effectiveness Data Information Set (HEDIS) and National Committee for Quality Assurance (NCQA). * Project planning experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $21.65 - $31.71 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. 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.

Provides support for pharmacy technician activities. Contributes to overarching pharmacy strategy for optimization of medication related health care outcomes, and quality cost-effective member care. Shift: (11 AM-7:30 PM MST or 12:30-9 PM MST) Essential Job Duties * Performs initial receipt and review of non-formulary or prior authorization requests against pharmacy plan approved criteria; requests additional information from providers as needed to properly evaluate requests. * Accurately enters approvals or denials of requests. * Facilitates prior authorization requests within established pharmacy policies and procedures. * Participates in the development/administration of pharmacy programs designed to enhance the utilization of targeted drugs and identification of cost-saving pharmacy practices. * Identifies and reports pharmacy departmental operational issues and resource needs to appropriate leadership. * Assists Molina member services, pharmacies, and health plan providers in resolving member prescription claims, prior authorizations, and pharmacy service access issues. * Articulates pharmacy management policies and procedures to pharmacy/health plan providers, Molina staff and others as needed. Required Qualifications * At least 2 years pharmacy technician experience, or equivalent combination of relevant education and experience. * Certified Pharmacy Technician (CPhT) and/or state pharmacy technician license (state specific if state required). If licensed, license must be active and unrestricted in state of practice. * Ability to abide by Molina policies. * Ability to maintain attendance to support required quality and quantity of work. * Ability to maintain confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPAA). * Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers. * Excellent verbal and written communication skills. * Microsoft Office suite (including Excel), and applicable software program(s) proficiency. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $21.65 - $31.71 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. 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.

**(Sales) Compliance Analyst** Molina Healthcare's Medicare Compliance team supports sales operations for the Molina Medicare product lines. It is a centralized corporate function supporting compliance activities. **KNOWLEDGE/SKILLS/ABILITIES** is primarily responsible for Sales Oversight. · Provide regulatory expertise to the Sales Organization: both State and Federal · Have working knowledge of federal and state guidelines pertaining to Sales and Marketing. · Perform internal Sales/Marketing Compliance Reporting. · Perform internal Sales/Marketing monitoring. · Detailed oriented to conduct thorough Sales allegations investigations. · Recommend applicable corrective action(s) when applicable to business partners. · Process improvement driven. · Create, update, and retire P&Ps, Standard Operating Procedures and Training documents. · Lead regularly scheduled Sales & Compliance leadership meetings. · Interpret and analyze Medicare, Medicaid, and MMP Required Sales & Marketing Reporting Technical Specifications. · Create and maintain monthly and quarterly Sales Complaint Key Performance Indicator (KPI) reports. · Review and interpret internal Sales dashboards for outliers and deeper dive research. · Manage compliance Sales Allegations, Secret Shops, and recommend corrective action plans for deficiencies found. · Responds to legislative inquiries/ Sales complaints (state insurance regulators, Congressional, etc.). · Leads projects to achieve Sales compliance objectives. · Interprets and analyzes state and federal regulatory manuals and revisions. · Interpret and analyze federal and state rules and requirements for proposed & final rules for Sales Oversight. · Interact with Molina external customers, via verbal and written communication. · Ability to work independently and set priorities. **Experience** · 2-4 years' related compliance work experience · Exceptional communication skills, including presentation capabilities, both written and verbal. · Excellent interpersonal communication and oral and written communication skills. · High level Interaction with Leadership. · Sales Allegation Investigations · Policy & Procedures Pay Range: $80,168 - $116,835 / ANNUAL *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility. **Position Purpose:** The Director of Digital and Database Marketing Strategy is an innovative and customer-centric leader who is responsible for developing and overseeing multichannel initiatives that help our brand connect with key stakeholders across different journeys and touchpoints. This leader has a player-coach mindset and can inspire, manage, and mentor a high-performing team in a dynamic and cross-functional environment. + Lead the creation of new initiatives to support the success of long-term digital strategies (including social media, web, video) and database marketing (text, email) + Oversee a team of five digital, social, and database marketing professionals + Lead digital communications and social media strategy, including audience development, content creation, and distribution across multiple platforms + Oversee the management and optimization of digital and social platforms, ensuring alignment with brand guidelines + Develop and manage a robust strategy for paid and organic content that is audience-centric, compelling, and aligns with business goals + Oversee creation and maintenance of web sites, including content, accessibility, design and performance + Collaborate with IT to improve the site's UX/UI, ensuring alignment with the company's branding and goals + Conduct regular audits to identify opportunities for optimization in content, navigation, SEO, and user flow + Develop and oversee enterprise video strategy + Develop and oversee the strategy, content, and implementation of email and text campaigns + Manage and optimize databases for personalized communication, ensuring segmentation, targeting, and automation are leveraged effectively to increase engagement and drive conversions + Identify, cultivate, and manage high-level relationships with experts in the digital space, platform representatives, and/or influencers + Evaluate and oversee preparation of competitive intelligence reports, analysis reports, and reputation dashboards + Maintain cutting-edge knowledge of trends, social platforms, and key developments in the industry + Performs other duties as assigned. + Complies with all policies and standards. **Education/Experience:** 10+ years of experience in Communications, Marketing, or related fields and 5+ years of leadership experience/managing teams. Digital/social media, analytics, and digital marketing expertise. **Experience with HTML/CSS/JavaScript, Technical SEO, UI/UX Design, SEM/GA360, Adobe Analytics, Salesforce CRM/Marketing Cloud.** **Travel Expectations -** Must be willing to travel in to the Long Island City office on a regular basis. Pay Range: $116,100.00 - $214,700.00 per year Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

Provides entry level 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** - Enters denials and requests for appeals into information system and prepares documentation for further review. - Researches claims issues utilizing systems and other available resources. - Assures timeliness and appropriateness of appeals according to state, federal and Molina guidelines. - Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research. - Determines appropriate language for letters and prepares responses to member appeals and grievances. - Elevates appropriate appeals to the next level for review. - Generates and mails denial letters. - Provides support for interdepartmental issues to help coordinate problem-solving in an efficient and timely manner. - Creates and/or maintains appeals and grievances related statistics and reporting. - Collaborates with provider and member services to resolve balance bill issues and other member/provider complaints. **Required Qualifications** - At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting, or equivalent combination of relevant education and experience. - Customer service experience. - Organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Effective verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting experience. - Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.65 - $34.88 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.