Specialist, Appeals & Grievances - Remote

Socket.dev; Long Beach (CA); Remote; USD 50,000 - 75,000; Full time

Job summary

Molina Healthcare is seeking a Claims Support Specialist to review and resolve member and provider complaints in accordance with CMS standards. The role encompasses appeals, disputes, and grievances handling with timely, accurate resolutions.

The ideal candidate has 2+ years in managed care claims environments, experience with Medicaid/Medicare denials, and strong communication skills. Proficiency in MS Office and ability to manage multiple tasks is essential.

Qualifications

• 2+ years of managed care experience in claims, appeals, or related environment.
• Health claims processing experience including COB, subrogation and eligibility.
• Experience with Medicaid and Medicare claims denials and appeals processing.
• Customer service experience.
• Strong organizational and time management skills to meet deadlines.
• Effective verbal and written communication skills.
• MS Office or equivalent software proficiency.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and complaints to meet regulatory timelines.
• Researches claims appeals and grievances using support systems to determine outcomes.
• Requests and reviews medical records and details to determine responses.
• Prepares appeal summaries and correspondence with findings.
• Composes responses to provider reconsideration requests and other inquiries.
• Resolves payment errors by researching processing guidelines and contracts.
• Contacts members/providers as needed via written and verbal communication.

Skills

Managed care experience

Customer service

Organizational & time management

Verbal & written communication

MS Office proficiency

Job description

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).

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