Lead Specialist, Appeals & Grievances (Remote)

Molina Healthcare, Inc.; Oregon; Hybrid; USD 60,000 - 90,000; Full time

Job summary

Molina Healthcare, Inc. seeks a lead-level claims support specialist to review and resolve member and provider complaints in compliance with CMS standards. The role operates in Pacific Time with an 8am–5pm PT shift. Based in Oregon, you will guide a team through appeals, grievances, and related workflows.

Ideal candidates have 3+ years in managed care claims, Medicaid/Medicare denials experience, strong customer service, and solid communication skills, with proficiency in Microsoft Office.

Qualifications

• 3+ years of managed care in call center, appeals, and/or claims.
• Health claims processing with benefits coordination and eligibility.
• Experience with Medicaid/Medicare denials and appeals processing.
• Strong customer service experience.
• Excellent organizational and time-management skills.
• Strong verbal and written communication skills.
• Proficiency in Microsoft Office and related software.

Responsibilities

• Lead handling of appeals, grievances, and complaints from members, providers, and outside agencies.
• Trains new staff and guides others on complex appeals and grievances.
• Resolves escalated issues including state complaints and high-visibility cases.
• Collaborates with claims leadership to assign work to team.
• Prepares appeal summaries, correspondence, and tracking data.
• Prepares drafts for narratives, graphs, flowcharts for audits and presentations.
• Requests and reviews records and bills; determines responses per protocols.
• Meets production standards in claims processing.
• Applies contract language and review of benefits and covered services.
• Contacts members and providers as needed.
• Documents findings and trends when requested.
• Writes correspondence and disputes per regulatory requirements.
• Researches processing guidelines and contracts to identify root causes.
• Responds to provider reconsideration requests and pay adjustments.

Skills

Managed care experience

Health claims processing

Medicaid/Medicare denials

Customer service

Organizational & time management

Verbal & written communication

Microsoft Office

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job Summary

Provides 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). This position will work in Pacific Time Zone. Please be open to a shift of 8am-5pm Pactific Time.

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).

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.