Specialist, Appeals & Grievances (Remote)

Molina Healthcare•Long Beach, CA

1d•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 researches and resolves appeals, disputes, grievances, and complaints; reviews relevant records and claims information; and prepares clear, accurate, and timely responses in accordance with applicable regulatory, state, federal, and Molina guidelines. It also investigates payment errors and responds to provider reconsideration requests and requests from outside agencies.

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.

Responsibilities

Research and resolve member and provider appeals, disputes, grievances, and complaints while meeting 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; develop conclusions in accordance with protocols and in collaboration with business partners.
Ensure responses are timely and appropriate under state, federal, and Molina guidelines.
Meet claims production standards established by the department.
Apply contract language, benefit provisions, and covered-service reviews to the claims review process.
Contact members and providers through written and verbal communications as needed.
Prepare appeal summaries and correspondence, document findings, and provide trend information as requested.
Compose concise and accurate correspondence about appeals, disputes, and grievances 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 concerning claims payments, claim adjustments, and requests from outside agencies.