Specialist, Appeals & Grievances (Members)- Remote

Molina Healthcare; Northern (KY); Hybrid; USD 21,000 - 44,000; Full time

Job summary

Molina Healthcare is seeking a Specialist for Members Appeals & Grievances to review and resolve member and provider complaints in compliance with CMS standards.

The role focuses on researching appeals, coordinating with internal teams, and communicating resolutions to members or authorized representatives. Strong organizational, verbal and written communication skills are essential.

Qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment.
• Experience with Medicaid and Medicare claims denials and appeals processing.
• Customer service experience and ability to manage multiple deadlines.
• Proficiency with Microsoft Office and relevant software.

Responsibilities

• Researches and resolves member, provider, and external appeals and grievances to meet timelines.
• Reviews medical records and bills to determine appeal outcomes.
• Communicates resolution to members or authorized representatives.
• Prepares appeal summaries and correspondence per regulatory requirements.
• Contacts members and providers as needed via written and verbal communication.

Skills

Customer service experience

Strong organizational skills

Verbal communication

Written communication

Microsoft Office proficiency

Education

Health care related vocational program (coding, billing, or medical assistant)

Tools

Microsoft Office Suite

Job description

Specialist, Members Appeals & Grievances

Mon - Fri

9am -6pm EST, 8am - 5pm CST, 7am -4pm MST, 6am -3pm PST

JOB DESCRIPTION Job Summary

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).

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).

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

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.