Lead Specialist, Appeals & Grievances (Remote)

Molina Healthcare•AZ, AZ

2d•$20 - $39•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 leads the submission, intervention, and resolution of appeals, grievances, and complaints; supports and guides team members; and researches escalated and complex cases. The position also prepares appeal summaries, correspondence, tracking information, and materials for presentations and audits. It reviews relevant medical records and claims information, applies contract language and benefit coverage, researches payment issues, and prepares written responses to provider reconsideration requests and inquiries from outside agencies. The role is responsible for accurate, timely, and appropriate responses under applicable state, federal, and Molina guidelines and for meeting departmental claims production standards.

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 and 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 coder, billing, or medical assistant.

Responsibilities

Lead submission, intervention, and resolution of appeals, grievances, and complaints from 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 with relevant business partners and ensure responses are timely and appropriate under applicable guidelines.
Meet claims production standards set by the department.
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, 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 adjustment requests, and requests from outside agencies.