Senior Specialist, Appeals & Grievances

Molina Healthcare•United States,

1d•$16 - $35

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 standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). The role researches and resolves complex, escalated, and high-dollar appeals, grievances, and complaints; reviews relevant records and claims information; determines outcomes under applicable protocols, contracts, benefits, regulations, and company guidelines; and prepares accurate, timely written responses and correspondence. The specialist also investigates payment errors, responds to provider reconsideration and adjustment requests, and identifies trends and operational deficiencies.

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 and meet internal deadlines.
Strong verbal and written communication skills.
Proficiency with Microsoft Office 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 training.

Responsibilities

Provide senior-level support for research and resolution of 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 with applicable protocols and business partners.
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.
Contact members and providers through written and verbal communications as needed.
Prepare appeal summaries and correspondence, and document findings.
Identify trends and operational deficiencies discovered through complaints.
Compose concise and accurate correspondence and appeals or grievance information in accordance with regulatory requirements.
Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine the root causes of payment errors.
Resolve and prepare written responses to provider reconsideration requests relating to claims payment, claim adjustment requests, and requests from outside agencies.