Specialist, Appeals & Grievances

Molina Healthcare; Orlando (FL); On-site; USD 23,000 - 44,000; Full time

Job summary

Molina Healthcare in Orlando, FL is seeking an experienced Claims Specialist to support provider appeals and claims activities in alignment with CMS standards. The role focuses on researching and resolving provider complaints and ensuring timely responses.

You will review medical records, coordinate with payers, prepare appeal summaries, and communicate findings to providers or authorized representatives. Strong organizational skills, customer service experience, and proficiency with Microsoft

Qualifications

• 2+ years of managed care appeals/claims experience.
• Experience with Medicaid/Medicare claims denials and appeals.
• Customer service experience.
• Strong organizational and time management skills.
• Proficient in Microsoft Office.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and complaints from Molina providers and outside agencies.
• Researches claims appeals and grievances to determine outcomes.
• Requests and reviews medical records and bills; forms conclusions per protocol.
• Prepares appeal summaries and correspondence with providers.
• Resolves and drafts responses to provider reconsideration requests.
• Ensures timeliness and compliance with regulations and Molina guidelines.

Skills

Managed care experience

Call center experience

Claims processing

Medicaid/Medicare denials & appeals

Customer service

Microsoft Office proficiency

Verbal and written communication

Time management

Tools

Microsoft Office

Job description

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.
• Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).
• 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.