Specialist, Appeals & Grievances

Molina Healthcare Inc; United States; On-site; USD 43,000 - 61,000; Full time

Job summary

Molina Healthcare Inc. seeks a detail-oriented Appeals Specialist to support pre service appeals across states, coordinating with members and providers under CMS standards. You will research, summarize, and respond to appeals in a timely, compliant manner.

The role requires at least 2 years in a managed care or claims environment, strong organizational skills, and proficiency with Microsoft Office. Excellent written and verbal communication are essential.

Qualifications

• 2+ years in a managed care, call center, appeals, and/or claims environment.
• Experience with Medicaid and Medicare claims denials and appeals processing.
• Strong communication skills, both written and verbal.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure timelines are met.
• Researches claims appeals and grievances using support systems to determine outcomes.
• Requests and reviews medical records and notes to formulate conclusions and responses within regulatory guidelines.

Skills

Appeals processing

Regulatory knowledge

Customer service

Microsoft Office

Research skills

Time management

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job Summary

Provides support for pre service appeals for members across all states throughout the organization, communicating with members and providers 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 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

• Experience with appeals for Medicare and Medicaid and the regulations with CMS.
• Experience with pre authorization appeals.
• Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).
• Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting.

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