Director, Appeals & Grievances (Medicare / Provider Claims) - REMOTE

Molina Healthcare; City of Albany (NY); Remote; USD 97,000 - 190,000; Full time

Job summary

A healthcare organization in Albany, NY is seeking a leader for the Grievance and Appeals Unit. This role involves directing the user experience of resolving member complaints in line with Medicare standards. The ideal candidate has extensive experience in healthcare claims and supervisory roles, with a strong focus on data analysis and process improvement.

Qualifications

• 7 years of experience in healthcare claims review and grievance processing.
• Experience in manager role for at least 2 years.
• Knowledge of Medicare grievance standards.

Responsibilities

• Lead and direct the Grievance and Appeals Unit activities.
• Monitor and train staff on processing member complaints.
• Establish and update grievance policies and procedures.

Skills

Healthcare claims review

Provider appeals processing

Grievance resolution

Supervisory experience

Education

Associate's degree

Bachelor's degree (preferred)

Job description

Job Description

Job Summary

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

Knowledge/Skills/Abilities

• Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with Centers for Medicare and Medicaid standards/requirements.

• Provides direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements related to non-contracted provider dispute/appeals processing.

• Establishes member and non-contracted provider grievance/dispute and appeals policies/procedures and updates annually or as directed by the Centers for Medicare and Medicaid Services.

• Trains grievance and appeals staff, customer/member services department, sales, UM and other departments within Molina Medicare and Medicaid on early recognition and timely routing of member complaints.

• Trains each state's provider dispute resolution unit on CMS standards and requirements, including the proper use of the Molina Provider Grievance and appeals system.

• Reviews and analyzes collective grievance and appeals data along with audit results on unit's performance; analyzes and interprets trends and prepares reports that identify root causes of member dissatisfaction; recommends and implements process improvements to achieve member/provider satisfaction or operational effectiveness/efficiencies which contribute to Molina Medicare's maximum STAR ratings.

Job Qualifications

Required Education

Associate's degree or 4 years of Medicare grievance and appeals experience.

Required Experience

• 7 years' experience in healthcare claims review and/or Provider appeals and grievance processing/resolution, including 2 years in a manager role.

• Experience reviewing all types of medical claims (e.g. CMS 1500, Outpatient/Inpatient, Universal Claims, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing), and IPA.

2 years supervisory/management experience with appeals/grievance processing within a managed care setting.

Preferred Education

Bachelor's degree.

Previous Director experience.

IPA support experience.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $97,299 - $189,679 / ANNUAL

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.