Specialist, Appeals & Grievances (Claims)

Molina Healthcare•Long Beach, FL

About The Position

The Specialist, Appeals & Grievances (Claims) supports 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 researches and resolves appeals, disputes, grievances, and complaints while meeting internal and regulatory timelines. It reviews claims and supporting documentation, applies contract language and benefit coverage, prepares accurate correspondence, and investigates payment errors and reconsideration requests.

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, with 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 health care-related vocational program, such as certified coder, billing, or medical assistant.

Responsibilities

Research and resolve appeals, disputes, grievances, and complaints from members, providers, and outside agencies within internal and regulatory timelines.
Use support systems to research claims appeals and grievances and determine appropriate outcomes.
Request and review medical records, notes, and detailed bills as appropriate; formulate conclusions according to protocols and in collaboration with business partners.
Ensure responses are timely and appropriate under state, federal, and Molina guidelines.
Meet departmental claims production standards.
Apply contract language, benefits, and covered-service reviews to the claims review process.
Contact members and providers as needed through written and verbal communications.
Prepare appeal summaries and correspondence, document findings, and provide trend information when requested.
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 identify 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.