Senior Appeals & Grievances Specialist (Claims)

Molina Healthcare, Inc.; United States; On-site; USD 60,000 - 90,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare, Inc. is seeking a senior-level Appeals Specialist to research and resolve complex, escalated, high-dollar appeals and grievances from members, providers, and external agencies.

You will review medical records and per-contract language to determine responses while meeting state, federal, and Molina guidelines. This role demands strong customer service, organizational and communication skills and a track record of timely, accurate correspondence.

Qualifications

• At least 3 years of managed care experience in a call center, appeals, and/or claims environment.
• Health claims processing experience, including coordination of benefits (COB), 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 proficiency.

Responsibilities

• Provides senior level support for comprehensive research and resolution of complex, escalated and high dollar appeals, grievances, and/or complaints from Molina members, providers and related outside agencies.
• Researches claims appeals and grievances using support systems to determine appeals and grievance 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 accordingly.
• Identifies trends and operational deficiencies discovered in complaints.
• 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 responses to incoming provider reconsideration requests relating to claims payment, requests for claim adjustments, and requests from outside agencies.

Skills

Managed care experience

Customer service

Time management

Verbal communication

Written communication

Tools

Microsoft Office

Job description

Molina Healthcare, Inc. is seeking a senior-level Appeals Specialist to research and resolve complex, escalated, high-dollar appeals and grievances from members, providers, and external agencies.

You will review medical records and per-contract language to determine responses while meeting state, federal, and Molina guidelines. This role demands strong customer service, organizational and communication skills and a track record of timely, accurate correspondence.