Lead Specialist, Appeals & Grievances

Molina Healthcare•Long Beach, AZ

About The Position

JOB DESCRIPTION Job Summary Provides lead 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 Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. Trains new employees and provides guidance to others with respect to complex appeals and grievances. Researches and resolves escalated issues including state complaints and high visible complex cases. In conjunction with claims leadership, assigns claims work to team. Prepares appeal summaries and correspondence, and documents information for tracking/trending data. Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances 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 guidelines. Meets claims production standards set by the department. Applies contract language, benefits, and review of covered services. Contacts members/providers via written and verbal communications as needed. Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested. Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements. Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors. Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies.

Requirements

At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria.
Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
Strong customer service experience.
Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
Strong 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.
Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).

Responsibilities

Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies.
Trains new employees and provides guidance to others with respect to complex appeals and grievances.
Researches and resolves escalated issues including state complaints and high visible complex cases.
In conjunction with claims leadership, assigns claims work to team.
Prepares appeal summaries and correspondence, and documents information for tracking/trending data.
Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances 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 guidelines.
Meets claims production standards set by the department.
Applies contract language, benefits, and review of covered services.
Contacts members/providers via written and verbal communications as needed.
Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested.
Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements.
Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors.
Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies.