Remote Lead for Appeals & Grievances: Claims & CMS Expert

Molina Healthcare; Arizona; Remote; USD 60.000 - 85.000; Vollzeit

Zusammenfassung

Molina Healthcare is seeking a lead-level claims professional to provide expert support for member and provider issues, including appeals and grievances, in line with CMS standards. The role involves guiding a team, reviewing complex cases, and preparing narratives and summaries for audits and presentations.

Responsibilities include collaborating with leadership, assigning work, researching root causes of payment issues, and ensuring timely, compliant responses to inquiries from members and

Qualifikationen

• At least 3 years of managed care experience in a call center, appeals, and/or claims environment.
• Experience with Medicaid/Medicare claims denials and appeals processing.
• Strong customer service and communication skills; ability to manage multiple tasks.
• Proficiency with MS Office and regulatory guidelines for appeals and denials.

Aufgaben

• Lead submission, intervention and resolution of appeals, grievances, and complaints.
• Train new employees and guide others on complex appeals and grievances.
• Research and resolve escalated issues including state complaints and complex cases.
• Assign claims work with claims leadership and prepare appeal summaries and correspondence.
• Document findings and trends; produce drafts for narratives, graphs and audits.
• Review medical records and determine response per protocol and Molina guidelines.
• Ensure timeliness and accuracy of communications to members and providers.
• Comply with regulatory requirements and contract language in responses.

Kenntnisse

Claims processing

Customer service

Team leadership

Regulatory knowledge

Tools

MS Office

Jobbeschreibung

Molina Healthcare is seeking a lead-level claims professional to provide expert support for member and provider issues, including appeals and grievances, in line with CMS standards. The role involves guiding a team, reviewing complex cases, and preparing narratives and summaries for audits and presentations.

Responsibilities include collaborating with leadership, assigning work, researching root causes of payment issues, and ensuring timely, compliant responses to inquiries from members and