Specialist, Appeals & Grievances - Remote

Molina Healthcare; Tallahassee (FL); Remote; USD 48,000 - 64,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare is seeking a Claims Appeals Specialist to support member and provider inquiries, review documentation, and communicate resolutions in accordance with CMS standards. The role emphasizes researching appeals, requesting medical records, and ensuring timely responses.

The position requires strong organizational skills, customer service experience, and proficiency with Microsoft Office in a fast-paced environment. PriorMedicaid/Medicare denials experience is preferred.

Qualifications

• At least 2 years of managed care experience in a claims/appeals environment.
• Health claims processing experience including COB, subrogation and eligibility criteria.
• Experience with Medicaid and Medicare denials and appeals processing.
• Customer service experience.
• Strong organizational and time management skills; ability to manage simultaneous projects and tasks.

Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and complaints to meet internal/regulatory timelines.
• Researches claims appeals and grievances to determine outcomes.
• Requests and reviews medical records, notes, and/or detailed bills; determines responses per protocol.
• Meets claims production standards.
• Applies contract language and review of benefits to the claims review process.
• Contacts members/providers via written and verbal communications.
• Prepares appeal summaries and correspondence; documents findings.
• Composes all correspondence related to appeals/grievances per regulatory requirements.
• Researches processing guidelines, provider contracts, and fee schedules to identify root causes of payment errors.
• Resolves and writes responses to provider reconsideration requests regarding payments/adjustments.

Skills

Customer service experience

Time management

Verbal communication

Tools

Microsoft Office

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).

Benefits

• Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.