Appeals & Grievances Specialist: Claims Resolution Expert

Molina Healthcare; Northern (KY); Hybrid; USD 20,000 - 44,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare in Kentucky is seeking a Claims Support Specialist to review and resolve member and provider complaints and communicate resolutions to members or authorized representatives in line with CMS standards.

The role involves researching appeals and grievances, requesting and reviewing medical records and bills, ensuring timely responses, and applying contract language and benefits rules to the claims review process.

Qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment.
• Experience with Medicaid and Medicare claims denials and appeals processing.
• Customer service experience.
• Strong organizational and time management skills; ability to manage multiple projects to meet deadlines.
• Effective verbal and written communication skills.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and/or complaints to meet internal and regulatory timelines.
• Researches claims appeals and grievances to determine appropriate outcomes.
• Requests and reviews medical records, notes, and/or bills; formulates conclusions per protocol.
• Meets claims production standards.
• Applies contract language and benefits review to the claims process.
• Contacts members/providers via written and verbal communications.
• Prepares appeal summaries and correspondence with findings.
• Researches processing guidelines to determine root causes of payment errors.
• Resolves provider reconsideration requests related to payments and adjustments.

Skills

Managed care experience

Claims processing

Customer service

Verbal & written communication

Microsoft Office proficiency

Tools

Microsoft Office

Job description

Molina Healthcare in Kentucky is seeking a Claims Support Specialist to review and resolve member and provider complaints and communicate resolutions to members or authorized representatives in line with CMS standards.

The role involves researching appeals and grievances, requesting and reviewing medical records and bills, ensuring timely responses, and applying contract language and benefits rules to the claims review process.