Associate Specialist, Appeals & Grievances

Molina Healthcare • Long Beach, FL

1d

About The Position

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).

Requirements

• 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.

Nice To Haves

• 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).

Responsibilities

• 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.

Benefits

• Molina Healthcare offers a competitive benefits and compensation package.
• Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees