Lead Specialist, Appeals & Grievances

Molina Healthcare; États-Unis; À distance; USD 70 000 - 100 000; Plein temps

Résumé du poste

Molina Healthcare is seeking a lead level professional to manage claims complaints, appeals, and grievances, ensuring timely resolutions and regulatory compliance. You will guide a team, prepare summaries, and coordinate with providers, members, and external agencies.

Ideal candidates bring 3+ years in managed care claims or appeals, experience with Medicaid/Medicare denial processes, and strong customer service and communication skills. Proficiency with MS Office is required.

Qualifications

• 3+ years in managed care claims or appeals environment.
• Experience with Medicaid/Medicare denials and appeals processing.
• Strong customer service orientation and communication skills.
• Ability to manage multiple tasks to meet deadlines.

Responsabilités

• Lead submission, intervention, and resolution of appeals and grievances.
• Train new employees and guide others on complex cases.
• Research and resolve escalated issues including state complaints.
• Prepare appeal summaries and tracking data.
• Communicate resolution to members or authorized representatives.

Connaissances

Managed care experience

Claims processing

Medicaid/Medicare denials

Customer service

Time management

Verbal and written communication

MS Office proficiency

Outils

MS Office

Description du poste

JOB DESCRIPTION Job SummaryProvides lead level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).

Essential Job Duties

• Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies.
• Trains new employees and provides guidance to others with respect to complex appeals and grievances.
• Researches and resolves escalated issues including state complaints and high visible complex cases.
• In conjunction with claims leadership, assigns claims work to team.
• Prepares appeal summaries and correspondence, and documents information for tracking/trending data.
• Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines.
• Meets claims production standards set by the department.
• Applies contract language, benefits, and review of covered services.
• Contacts members/providers via written and verbal communications as needed.
• Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested.
• Composes all correspondence, appeals/disputes, and/or grievances information concisely and accurately, and in accordance with regulatory requirements.
• Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors.
• Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and/or requests from outside agencies.

Required Qualifications

• At least 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
• Health claims processing experience, including coordination of benefits, subrogation and eligibility criteria.
• Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Strong customer service experience.
• Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting.
• Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).

• the company offers a competitive benefits and compensation package.

the company is an Equal Opportunity Employer (EOE) M/F/D/V.

Originally posted on Himalayas