Specialist, Appeals & Grievances Members - Remote (CST)

Molina Healthcare•Long Beach, CA

4d•Remote

About The Position

Provides support for claims activities by 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 supports Medicaid and Marketplace members and works Monday through Friday, 8 a.m. to 5 p.m. Central time. The position is remote. The specialist researches and resolves appeals, disputes, grievances, and complaints; reviews claims and related records; determines outcomes under applicable protocols and guidelines; and prepares accurate, timely correspondence. The role also investigates claims payment issues, responds to provider reconsideration requests, and meets departmental production standards.

Requirements

At least 2 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.
Customer service experience.
Strong organizational and time management skills, including the ability to manage simultaneous projects and tasks to meet internal deadlines.
Effective 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 training.

Responsibilities

Research and resolve member and provider appeals, disputes, grievances, and complaints while meeting internal and regulatory timelines.
Research claims appeals and grievances using support systems to determine appropriate outcomes.
Request and review medical records, notes, and detailed bills as appropriate; formulate conclusions in accordance with protocols and coordinate with business partners as needed.
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 as part of the claims review process.
Contact members and providers as needed through written and verbal communications.
Prepare appeal summaries and correspondence, document findings, and provide information on trends when requested.
Compose concise and accurate correspondence concerning appeals, disputes, and grievances in accordance with regulatory requirements.
Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine root causes of payment errors.
Resolve and prepare written responses to provider reconsideration requests related to claims payment, requests for claim adjustments, and requests from outside agencies.