Specialist, Appeals & Grievances Medicaid - Remote (CST Hours)

UnitedHealth Group; United States; Teletrabalho; USD 21 000 - 44 000; Tempo integral

Resumo da oferta

Molina Healthcare is seeking a Claims Appeals Specialist to support claims activities, review member and provider complaints, and communicate resolutions in line with CMS standards.

You will research appeals and grievances, request and review medical records, prepare summaries, and ensure timely responses while applying contract language and benefits rules. A customer-focused professional with Medicare/Medicaid experience excels here.

Qualificações

• At least 2 years of managed care experience in appeals/claims environment.
• Experience with Medicaid and Medicare claims denials and appeals processing.
• Health claims processing experience including COB, subrogation, and eligibility.
• Customer service experience.
• Strong organizational and time-management skills.
• Effective verbal and written communication skills.
• MS Office proficiency.

Responsabilidades

• Research appeals and grievances to meet internal and regulatory timelines.
• Review medical records and bills to determine outcomes.
• Prepare appeal summaries and correspondence.
• Contact members/providers as needed.
• Identify root causes of payment errors and address them.
• Comply with CMS and regulatory guidelines.

Conhecimentos

Customer service

Time management

Verbal & written communication

Microsoft Office

Ferramentas

Microsoft Office

Descrição da oferta de emprego

JOB DESCRIPTION Job SummaryProvides 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).

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

• 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).

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

Pay Range: $14.76 - $31.97 / HOURLY

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