Specialist, Appeals & Grievances - Remote

Molina Healthcare • Ann Arbor, MI • 17h 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

2nd Shift Transaxle Test Support Technician

V2soft Inc. • Ann Arbor, MI • 21min ago

IT & Engineering

Requirements: CANDIDATE MUST BE ABLE TO WORK 2ND SHIFT 3-11:30PM Requirements: High School Diploma or Equivalent: Basic education is essential Technical Degree or Certification: An associate degree in automotive technolo...

21min ago

Go to Apply

Engineer BS Degree

V2soft Inc. • Ann Arbor, MI • 1h ago

IT & Engineering

V2Soft is a global leader in IT services and business solutions, delivering innovative and cost-effective technology solutions worldwide since 1998. We have headquartered in Bloomfield Hills, MI and have 16 offices sprea...

1h ago

Go to Apply

Field Service Representative - University of Michigan 4871

Daniels Sharpsmart Inc • Ann Arbor, MI • 1h ago

Management & Administrative

Daniels Health is searching for a customer service oriented individual to join us as a Field Service Representative. This position is responsible for the inspection and servicing of all products within their assigned hos...

1h ago

Go to Apply

Mechanical Engineer

Sweepster Attachments LLC • Dexter, MI • 2h ago

IT & Engineering

United. Inspired. Performance unites us, innovation inspires us, and commitment drives us to keep moving forward. All new thinkers are welcome. We are looking for candidates who want to develop, grow, and dare to think n...

2h ago

Go to Apply

Security Professional Flex Officer - Bank

Allied Universal • Ypsilanti, MI • 11h ago

Finance, Accounting & Banking

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...

11h ago

Go to Apply

Assistant Manager I

Dollar Tree • Ypsilanti, MI • 16h ago

Retail & Hospitality

We're seeking an Assistant Store Manager to join our team to help with store operations, customer service and team development. Duties include, but are not limited to, the following: Assist with store functions and day-t...

16h ago

Go to Apply

Analyst, Business Quality (Remote)

Molina Healthcare • Ann Arbor, MI • 16h ago

IT & Engineering

Job Description Job Summary Assist business teams with developing requirements for major projects of considerable complexity, prepares system design specifications, conducts research to resolve customer initiated issues...

16h ago

Go to Apply

Lead Specialist, Appeals & Grievances - Remote

Molina Healthcare • Ann Arbor, MI • 17h ago

JOB DESCRIPTION Job Summary Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member and provider complaints and communicat...

17h ago

Go to Apply

Senior Manager, Product Marketing

Thomson Reuters Holdings Inc • Ann Arbor, MI • 18h ago

Management & Administrative

We are looking for a highly strategic and results-oriented Senior Manager for the Corporates Product Marketing team, focusing on ourCorporates Tax & Trade - ONESOURCEportfolio. This role will include leading analytic...

18h ago

Go to Apply

Product Marketing Manager

Thomson Reuters Holdings Inc • Ann Arbor, MI • 18h ago

Management & Administrative

About the Role:We are seeking a results-oriented and collaborative Product Marketing Manager to drive the marketing strategy and execution for ourONESOURCE Pagero and e-invoicing solutions. This role will be primarily re...

18h 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.