Lead Specialist, Appeals & Grievances (Remote)

Molina Healthcare•Long Beach, AZ

1d•Remote

About The Position

Provides lead-level support for claims activities, including reviewing and resolving member and provider complaints and communicating resolutions to members or authorized representatives in accordance with Centers for Medicare and Medicaid Services (CMS) standards and requirements. Serves as a team lead for appeals, grievances, and complaints; supports colleagues with complex cases; researches and resolves escalated issues; and helps assign claims work in conjunction with claims leadership. The role also prepares summaries, correspondence, documentation, and presentation materials; reviews relevant medical and billing records; researches claims and payment issues; and prepares responses to reconsideration requests and outside agencies. Responses must be timely and appropriate under state, federal, and Molina guidelines.

Requirements

At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or an 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, including the ability to manage simultaneous projects and tasks to meet internal deadlines.
Strong verbal and written communication skills.
Proficiency with Microsoft Office suite and applicable software programs.

Nice To Haves

Customer or provider experience in a managed care organization (Medicaid, Medicare, Marketplace, and/or another government-sponsored program), or in a medical office or hospital setting.
Completion of a health care-related vocational program, such as certified coding, billing, or medical assistant training.

Responsibilities

Lead the submission, intervention, and resolution of appeals, grievances, and complaints from members, providers, and related outside agencies.
Train new employees and guide others on complex appeals and grievances.
Research and resolve escalated issues, including state complaints and high-visibility complex cases.
Assign claims work in conjunction with claims leadership.
Prepare appeal summaries and correspondence, and document information for tracking and trending.
Prepare draft narratives, graphs, flowcharts, and other materials for presentations and audits.
Research claims appeals and grievances using support systems to determine outcomes.
Request and review medical records, notes, and detailed bills as appropriate; formulate conclusions in accordance with protocols and consult business partners to determine responses.
Ensure responses are timely and appropriate under state, federal, and Molina guidelines.
Meet department claims production standards.
Apply contract language and benefits, and review covered services.
Communicate with members and providers in writing and verbally as needed.
Compose concise, accurate correspondence and appeals, disputes, or grievance information in accordance with regulatory requirements.
Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine the root cause of payment errors.
Resolve and prepare written responses to provider reconsideration requests relating to claims payment, claim adjustments, and requests from outside agencies.