Specialist, Appeals & Grievances (MST business hours)

Molina Healthcare; United States; On-site; USD 50,000 - 75,000; Full time

Job summary

Molina Healthcare in the United States is seeking a Claims Specialist to support CMS-aligned processes. You will review and resolve member and provider complaints, preparing timely responses and appeal summaries.

The role requires 2+ years in managed care claims, COB/denials experience, and strong communication skills. Typical hours are MST 8am-5pm with rotating weekends/holidays. Competitive benefits apply.

Qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment.
• Healthcare claims processing experience including COB, subrogation and eligibility.
• Experience with Medicaid/Medicare claims denials and appeals processing.
• Strong written and verbal communication skills.
• Effective time management and ability to handle multiple tasks to meet deadlines.
• Proficiency with Microsoft Office and related software.

Responsibilities

• Research and resolve appeals, disputes, grievances, and complaints to meet regulatory timelines.
• Research claims appeals and grievances using support systems to determine outcomes.
• Request and review medical records and bills; determine responses per protocol.
• Meet claims production standards set by the department.
• Apply contract language and benefits to claims review process.
• Contact members/providers via written and verbal communications as needed.
• Prepare appeal summaries and documentation of findings.
• Compose correspondence and disputes in accordance with regulatory requirements.
• Research processing guidelines and contracts to determine root causes of payment errors.
• Respond to provider reconsideration requests related to claims payment and adjustments.

Skills

Verbal communication

Written communication

Time management

Organizational skills

Multitasking

Customer service

Education

Healthcare vocational program

Tools

MS Office

Job description

Employee for this role will work MST 8am-5pm. Rotating weekends/holidays are required.

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).

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