Specialist, Appeals & Grievances (Remote)

Molina Healthcare • Milwaukee, WI • 6h ago

JOB DESCRIPTION

Job Summary

Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

KNOWLEDGE/SKILLS/ABILITIES

Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.

Research claims appeals and grievances using support systems to determine appeal 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 Healthcare guidelines.

Responsible for meeting production standards set by the department.

Apply contract language, benefits, and review of covered services

Responsible for contacting the member/provider through written and verbal communication.

Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.

Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.

Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.

Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies

JOB QUALIFICATIONS

REQU IRED ED UC ATI ON :

High School Diploma or equivalency

REQU IRED E XPE RI EN CE:

Min. 2 years operational managed care experience (call center, appeals or claims environment).

Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.

Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.

Strong verbal and written communication skills

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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

Pay Range: $21.16 - $38.37 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Similar Jobs

PHYSICAL THERAPIST, FMFH - REHAB SERVICE

FROEDTERT HEALTH • Menomonee Falls, WI • 1h ago

Hospital & Medical

JOB REQUIREMENTS: Discover. Achieve. Succeed. #BeHere Location: US:WI:MENOMONEE FALLS at our FROEDTERT MEN FALLS HOSPITAL facility. This job is ON - SITE. FTE: 0.900000 Shift: Shift 1 Job Summary: The Physical Therapist...

1h ago

Go to Apply

Oracle Cloud Finance - Senior Associate

PwC • Milwaukee, WI • 6h ago

Finance & Accounting

Specialty/Competency: Oracle Industry/Sector: Not Applicable Time Type: Full time Travel Requirements: Up to 60% A career in our Finance team, within our Oracle consulting practice, will provide you with the opportunity...

6h ago

Go to Apply

Strategic OEM Marketing Manager

ROCKWELL AUTOMATION INC. • Milwaukee, WI • 6h ago

Management & Administrative

JOB REQUIREMENTS: Milwaukee, Wisconsin, United States Mayfield Heights, Ohio, United States Rockwell Automation is a global technology leader focused on helping the world\'s manufacturers be more productive, sustainable,...

6h ago

Go to Apply

Distributor Marketing Specialist

ROCKWELL AUTOMATION INC. • Milwaukee, WI • 6h ago

Sales & Marketing

6h ago

Go to Apply

North America Field Marketing Sr.

ROCKWELL AUTOMATION INC. • Milwaukee, WI • 6h ago

Sales & Marketing

JOB REQUIREMENTS: Milwaukee, Wisconsin, United States Rockwell Automation is a global technology leader focused on helping the world\'s manufacturers be more productive, sustainable, and agile. With more than 28,000 empl...

6h ago

Go to Apply

Product Manager Training Services

ROCKWELL AUTOMATION INC. • Milwaukee, WI • 6h ago

Management & Administrative

JOB REQUIREMENTS: Mayfield Heights, Ohio, United States Milwaukee, Wisconsin, United States Rockwell Automation is a global technology leader focused on helping the world\'s manufacturers be more productive, sustainable,...

6h ago

Go to Apply

Loan Collections Specialist

Insight Global • Milwaukee, WI • 6h ago

Finance & Accounting

Job Description sition Summary: The Loan Collections Specialist is responsible for managing and resolving delinquent loan accounts. This role involves contacting borrowers to negotiate repayment plans, processing payment...

6h ago

Go to Apply

Assistant Coach, Women's Lacrosse

MARQUETTE UNIVERSITY • Milwaukee, WI • 6h ago

JOB REQUIREMENTS: Assistant Coach, Women\'s Lacrosse Posting Number: NA01485 Employment Status: Full Time Job Family: Athletic Coaching, Training, and Program Management Position Overview Responsible for supporting the H...

6h ago

Go to Apply

Treasury Analyst II

REXNORD • Milwaukee, WI • 6h ago

Finance & Accounting

JOB REQUIREMENTS: Job Overview: We are seeking a highly detail-oriented Treasury Analyst II to join our dynamic finance team. The successful candidate will play a crucial role in the execution of foreign exchange and com...

6h ago

Go to Apply

Major Account Manager Spectrum Business

SPECTRUM • Milwaukee, WI • 6h ago

Management & Administrative

JOB REQUIREMENTS: Do you want to use your sales expertise to create the overall module and account pursuit strategy? You can do that. Ready to use consultative sales techniques to simplify the communication needs of stra...

6h ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.