Specialist, Appeals & Grievances (Member/Provider Exp. Required)

JOB DESCRIPTION

Job Summary

Responsible for reviewing and resolving member and provider complaints/disputes and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

KNOWLEDGE/SKILLS/ABILITIES

• Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.

• Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.

• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines.

• Responsible for meeting production standards set by the department.

• Apply contract language, benefits, and review of covered services

• Responsible for contacting the member/provider through written and verbal communication.

• Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.

• Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.

• Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.

• Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies

JOB QUALIFICATIONS

REQUIRED EDUCATION:

High School Diploma or equivalency

REQUIRED EXPERIENCE:

• Min. 2 years operational managed care experience (appeals or claims processing).

• Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.

• Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.

• 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: $14.76 - $31.97 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.