Supervisor, Appeals & Grievances - Remote (PST)

Molina Healthcare•Long Beach, CA

3d•Remote

About The Position

The Supervisor, Appeals & Grievances leads and supervises a team responsible for claims-related activities, including reviewing and resolving member and provider complaints and communicating resolutions to members or authorized representatives. The role ensures that appeals and grievance handling complies with standards and requirements established by the Centers for Medicare and Medicaid Services (CMS), as well as applicable federal, state, and Molina guidelines. The position must work Pacific Standard Time hours.

Requirements

At least 4 years of operational managed care experience in a call center, appeals, and/or claims environment, or an equivalent combination of relevant education and experience.
Experience reviewing medical claims, including HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high-dollar complicated claims, COB, and DRG/RCC pricing.
Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
Previous experience leading projects.
Strong verbal and written communication skills.
Strong customer service experience.
Strong organizational and time-management skills, including the ability to manage simultaneous projects and tasks to meet internal deadlines.
Proficiency with the Microsoft Office suite.

Nice To Haves

Management or leadership experience.
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 training.

Responsibilities

Supervise the team responsible for submitting and resolving member and provider appeals and grievances, ensuring resolutions comply with applicable standards and requirements.
Assess and audit business processes to determine effective and efficient ways to resolve member and provider grievances.
Coordinate with corporate counterparts and member services to ensure standards and processes align with federal, state, and Molina guidelines.
Oversee preparation of narratives, graphs, flowcharts, and other materials for committee presentations, audits, and internal or external reports.
Oversee correspondence prepared in accordance with regulatory requirements.
Ensure the department's claims production standards are met.
Maintain a call tracking system and a database of correspondence and outcomes for provider and member appeals.
Monitor appeals to ensure internal and regulatory timelines are met.