Manager, Appeals & Grievances

Molina Healthcare•Long Beach, CA

About The Position

Leads and manages a team responsible for claims activities, including reviewing and resolving member and provider complaints, and communicating resolutions 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 7 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
At least 1 year management/leadership experience.
Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high-dollar complicated claims, COB and DRG/RCC pricing).
Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
Previous experience leading projects.
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

Manages team responsible for the submission/resolution of member and provider appeals and grievances; ensures resolutions are compliant with applicable standards and requirements.
Assesses and audits business processes to determine effective and efficient resolution of member and provider grievances.
Serves as primary interface with stakeholders and business partners, and ensures standard processes are implemented.
Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.
Ensures claims production standards set by the department are met.
Maintains call tracking system of correspondence and outcomes for provider and member appeals/grievances; oversees/monitors appeals to ensure all internal and regulatory timelines are met.