Lead Specialist, Appeals & Grievances (Remote)

Molina Healthcare•Long Beach, CA

2d•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. The role serves as a team lead for appeals, grievances, and complaints; guides and trains employees; researches escalated and complex issues; and supports claims-work assignment. It prepares appeal summaries, correspondence, tracking documentation, and presentation or audit materials. The position researches claims and relevant policies, reviews medical records and bills as appropriate, determines outcomes and responses with business partners, and ensures responses are timely and appropriate under applicable state, federal, and Molina guidelines. It also applies contract terms and benefits, communicates with members and providers, investigates payment errors, and responds to provider reconsideration and claim-adjustment requests.

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 submission, intervention, and resolution of appeals, grievances, and complaints from Molina members, providers, and 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 to the team 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 according to protocol and in collaboration with business partners.
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.
Contact members and providers through written and verbal communications as needed.
Compose concise and accurate correspondence and appeals, disputes, and 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 related to claims payment, claim adjustments, and requests from outside agencies.