Specialist, Appeals & Grievances - Remote EST Hours

Molina Healthcare; United States; À distance; USD 31 000 - 67 000; Plein temps

Résumé du poste

Molina Healthcare is seeking a Claims Appeals Specialist to support the review, resolution, and communication of member and provider complaints in compliance with CMS standards.

The role emphasizes research of appeals and grievances, review of medical records, and timely responses. Strong communication, organization, and familiarity with Medicaid/Medicare guidelines are essential.

Qualifications

• At least 2 years of managed care experience in a call center, appeals, or claims environment.
• Experience with Medicaid/Medicare claims denials and appeals processing.
• Strong verbal and written communication skills.

Responsabilités

• Researches and resolves appeals, disputes, grievances, and complaints to meet timelines.
• Reviews medical records and applies protocol to determine response.
• Maintains claims production standards.
• Applies contract language and review of benefits in claims reviews.
• Contacts members/providers by written and verbal communications.
• Prepares appeal summaries and documents findings.
• Composes correspondence for appeals and grievances in regulatory compliance.
• Investigates payment errors and root causes via guidelines and contracts.
• Resolves provider reconsideration requests related to claims payment.

Connaissances

Managed care experience

Call center

Regulatory knowledge

Communication skills

Time management

Formation

Health care vocational program

Outils

Microsoft Office

Description du poste

M-F 8:30am - 5pm EST must be flexiable to work on weekends due to buisness needs.

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.

Pay Range: $14.76 - $31.97 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.