Senior Specialist, Appeals & Grievances

Molina Healthcare•Long Beach, CA

About The Position

Provides senior-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 researches and resolves complex, escalated, and high-dollar appeals, grievances, and complaints; reviews relevant medical and claims documentation; and prepares timely, accurate responses in accordance with applicable state, federal, and Molina guidelines. The position also investigates claims payment issues, responds to provider reconsideration requests, and identifies operational trends and deficiencies. The listed schedule is Monday through Friday, with hours varying by time zone: 7 a.m.–4 p.m. PST, 8 a.m.–5 p.m. MST, 9 a.m.–6 p.m. CST, or 10 a.m.–7 p.m. EST.

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 (COB), 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, with 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 healthcare-related vocational program, such as certified coder, billing, or medical assistant.

Responsibilities

Provide senior-level support for researching and resolving complex, escalated, and high-dollar appeals, grievances, and complaints from members, providers, and outside agencies.
Research claims appeals and grievances using support systems to determine outcomes.
Request and review medical records, notes, and detailed bills as appropriate; formulate conclusions and coordinate with business partners to determine responses.
Ensure responses are timely and appropriate under state, federal, and Molina guidelines.
Meet claims production standards set by the department.
Apply contract language and benefits, and review covered services.
Communicate with members and providers in writing and verbally as needed.
Prepare appeal summaries and correspondence, and document findings.
Identify trends and operational deficiencies found through complaints.
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 regarding claims payment, claim adjustment requests, and requests from outside agencies.