Specialist, Appeals & Grievances (Must Reside in Easter Time Zone)

Molina Healthcare • Lowell, MA • 3h 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

Admission/Liaison RN Hospice

Tufts Medicine • Lowell, MA • 1h ago

Hospital & Medical

Job Description Minimum Qualifications : Massachusetts RN Licensure. Hospice and/or end of life experience required. Location : Lowell MA Hours : Full Time- 40 Hours Monday-Friday No Weekends (Days) Duties and Responsibi...

1h ago

Go to Apply

Admission RN Hospice

Tufts Medicine • Lowell, MA • 1h ago

Hospital & Medical

Job Overview The position is a member of the hospice staff who determines appropriateness of referrals, coordinates and conducts pre-admission activities, completes admission when determined hospice appropriate, monitors...

1h ago

Go to Apply

Assembler B

Boyd • Woburn, MA • 2h ago

Manufacturing & Warehouse

Job Description: This is a Temp to Perm All Job Posting Locations (Location) Woburn Remote Type On-Site EEO Statement Boyd Corp is an equal opportunity employer. We celebrate diversity and are committed to creating an in...

2h ago

Go to Apply

Amazon Locker+ Retail Associate

Amazon • Nashua, NH • 2h ago

Retail & Hospitality

Amazon Locker+ Retail Associate Job Overview You're on your way to joining the dedicated team at Amazon that makes the return and pickup of packages convenient for our customers at our Locker+ retail locations. We are lo...

2h ago

Go to Apply

Amazon Locker+ Retail Associate

Amazon • Lynnfield, MA • 2h ago

Retail & Hospitality

2h ago

Go to Apply

Anesthesia Tech, OR - 40 hours, rotating schedule

Beth Israel Lahey Health • Winchester, MA • 2h ago

Hospital & Medical

Job Type: Regular Time Type: Full time Work Shift: Rotating (United States of America) FLSA Status: Non-Exempt When you join the growing BILH team, you're not just taking a job, you're making a difference in people's liv...

2h ago

Go to Apply

Security Shift Supervisor

Allied Universal • North Andover, MA • 4h ago

Allied Universal®, North America's leading security and facility services company, offers rewarding careers that provide you a sense of purpose. While working in a dynamic, welcoming, and collaborative workplace, you wil...

4h ago

Go to Apply

Part-Time Hitch Installer

U-Haul • Wilmington, MA • 5h ago

Location: 687 Main St Rte 38, Wilmington, Massachusetts 01887 United States of America Do you enjoy working with your hands? Are you interested in learning valuable technical skills? U-Haul is seeking a hard-working, kno...

5h ago

Go to Apply

Clinical Associate (36-Hrs) Nights, Float Pool

Beth Israel Lahey Health • Winchester, MA • 6h ago

Hospital & Medical

Job Type: Regular Time Type: Full time Work Shift: Night (United States of America) FLSA Status: Non-Exempt When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives....

6h ago

Go to Apply

Hospice RN Weekend Baylor

Beth Israel Lahey Health • Woburn, MA • 6h ago

Hospital & Medical

Job Type: Regular Time Type: Full time Work Shift: Day (United States of America) FLSA Status: Exempt When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives. Job D...

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.