Specialist, Appeals & Grievances

Molina Healthcare•United States,

3d•$15 - $32

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 claims and supporting documentation; applies contract and coverage rules; and prepares accurate, timely, regulatory-compliant responses and correspondence. It also investigates claims payment errors and handles provider reconsideration and adjustment 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, 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 health care-related vocational program, such as certified coding, billing, or medical assistant training.

Responsibilities

Research and resolve appeals, disputes, grievances, and complaints from members, providers, and outside agencies 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 and ensure responses are timely and appropriate under state, federal, and Molina guidelines.
Meet departmental claims production standards.
Apply contract language, benefits, and covered-service review 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 concerning 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 related to claims payment, claim adjustments, and requests from outside agencies.