Specialist, Appeals & Grievances

Molina Healthcare; California (MO); On-site; USD 29,825 - 52,858; Full time

Benefits offered by this job

Competitive benefits package

Equal Opportunity Employer

Job summary

A health care organization is seeking a Specialist, Appeals & Grievances to support claims activities by resolving member and provider complaints. The ideal candidate will have at least 2 years of managed care experience and a strong understanding of health claims processing. Responsibilities include conducting research on grievances, meeting department standards, and communicating resolutions. A competitive hourly wage and benefits are offered. This role is full-time and entry-level, suitable for motivated individuals ready to contribute to a vital healthcare mission.

Qualifications

• Minimum of 2 years managed care experience in a relevant environment.
• Experience with Medicaid and Medicare claims denials and appeals processing.
• Proficient in Microsoft Office and applicable software.

Responsibilities

• Research and resolve appeals, grievances, and complaints.
• Meet claims production standards set by the department.
• Communicate findings and prepare appeal summaries.

Skills

Managed care experience

Health claims processing

Customer service experience

Organizational skills

Effective communication skills

Microsoft Office proficiency

Education

Relevant education in health care

Job description

Job Title

Specialist, Appeals & Grievances

Company

Molina Healthcare

Overview

Provides 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).

Responsibilities

• Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met.
• Researches claims appeals and grievances using support systems to determine appropriate 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 to claims review process.
• Contacts members/providers as needed via written and verbal communications.
• Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested).
• Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements.
• Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.
• Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies.

Required Qualifications

• At least 2 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 (COB), subrogation and eligibility criteria.
• Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Customer service experience.
• Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Effective 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).

Internal Applicants

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Benefits & Compensation

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

Pay Range: $21.65 - $38.37 / HOURLY

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

Seniority Level

Entry level

Employment Type

Full-time

Job Function

Other

Industry

Hospitals and Health Care