Specialist, Appeals & Grievances

Molina Healthcare; Florida; On-site; USD 23,000 - 44,000; Full time

Job summary

Molina Healthcare in Florida is seeking a Claims Appeals Specialist to support provider appeals, disputes and complaints and to communicate timely resolutions in accordance with CMS standards. You will research claims, gather medical records and documents, determine outcomes, prepare appeal summaries, and formally communicate results to providers or their authorized representatives.

Requires 2+ years in managed care claims/appeals, strong organizational and communication skills, and proficiency

Qualifications

• At least 2 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.
• 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/proficiency.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and/or complaints from Molina providers and related outside agencies to ensure timelines are met.
• Researches claims appeals and grievances using support systems to determine appropriate outcomes.
• Requests and reviews medical records, notes, and bills; formulates conclusions per protocol and partners to determine response; ensures timely responses per guidelines.
• Meets claims production standards set by the department.
• Applies contract language, benefits and review of covered services to the claims review process.
• Contacts providers as needed via written and verbal communications.
• Prepares appeal summaries and correspondence, and documents findings with trends as requested.
• Composes all correspondence and disputes in accordance with regulatory requirements.
• Researches processing guidelines, provider contracts, fee schedules to determine root causes of errors.
• Resolves and prepares written response to provider reconsideration requests related to claims payment and adjustments.

Skills

Managed care experience

Call center experience

Claims processing

COB-subrogation-eligibility

Medicaid/Medicare denials & appeals

Customer service

Organizational skills

Time management

Verbal and written communication

Microsoft Office proficiency

Tools

Microsoft Office

Job description

Job Summary

Provides support for claims activities including reviewing and resolving provider complaints, and communicating resolution to providers or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).

Essential Job Duties

• Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina 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 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.
• Strong claims processing experience, including demonstrated knowledge of claim review,claim denials, coordination of benefits (COB), and eligiblity criteria.

Molina Healthcare offers a competitive benefits and compensation package.

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

Pay Range: $16.4 - $31.97 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.