Specialist, Appeals & Grievances - Remote

Molina Healthcare • Fort Worth, TX • 1d 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

Strategic Marketing Director

ITW • Fort Worth, TX • 14min ago

Sales & Marketing

Job Description: ABOUT THE BRAND Illinois Tool Works Inc. (NYSE: ITW) is a Fortune 200 global multi-industry manufacturing leader with revenue of $15.9 billion in 2024. The company's seven industry-leading segments lever...

14min ago

Go to Apply

Tire and Lube Technician

The Hertz Corporation • Dallas-Fort Worth International Airport, TX • 1h ago

Retail & Hospitality

We are looking for a Tire and Lube Technician with a passion to service vehicles. If this is, you and you're ready for your next destination then you have cruised to the right spot! Wage : $16.00 hourly Apply today and s...

1h ago

Go to Apply

Supply Chain Management Coordinator (Remote)

POWER Engineers • Fort Worth, TX • 1h ago

Management & Administrative

Supply Chain Management Coordinator (Remote) Location Nationwide Secondary Locations Job Code 18696 of openings 2 Apply Now ( https://phh.tbe.taleo.net/phh04/ats/careers/v2/applyRequisition?org=POWERENGINEERS&cws=44&...

1h ago

Go to Apply

Customer Service Representative

U-Haul • Fort Worth, TX • 2h ago

Management & Administrative

Location: 3019 Altamesa Blvd, Fort Worth, Texas 76133 United States of America Are you a people person? Do you love helping others? U-Haul is in search of friendly, motivated people for the position of Customer Service R...

2h ago

Go to Apply

Customer Service Representative

UnitedHealth Group • Fort Worth, TX • 2h ago

Management & Administrative

This position is Remote within the states of Texas, North Carolina, Florida, Georgia, Missouri, Indiana, South Carolina, Arizona, Kansas, Kentucky OR Oklahoma. Optum is a global organization that delivers care, aided by...

2h ago

Go to Apply

Customer Service - Self Storage Manager

Public Storage • Benbrook, TX • 3h ago

Management & Administrative

Company Description Public Storage is the self-storage industry leader and we are Hiring Now! Earn $15.00 Per Hour Our Benefits Total Rewards package available to our team: We work Flexible and Full-Time Schedules betwee...

3h ago

Go to Apply

Warehouse

Aaron's Inc • Benbrook, TX • 3h ago

Manufacturing & Warehouse

Overview The salary range for this role is $15.00 to $17.00 per hour.* Warehouse personnel duties include the unloading of trucks for receiving/processing of incoming stock and materials, picking product from stock and l...

3h ago

Go to Apply

Truck Driver - Class A

Performance Food Group • Fort Worth, TX • 3h ago

Trucking & Construction

127692BR Job Title: Truck Driver - Class A Location: CM FortWorth, TX (2572) Job Description: We Deliver the Goods: Competitive pay and benefits, including Day 1 Health & Wellness Benefits, Employee Stock Purchase Pl...

3h ago

Go to Apply

Warehouse Associate - Forklift (Days)

Performance Food Group • Fort Worth, TX • 3h ago

Manufacturing & Warehouse

127640BR Job Title: Warehouse Associate - Forklift (Days) Location: CM FortWorth, TX (2572) Job Description: We Deliver the Goods: Competitive pay and benefits, including Day 1 Health & Wellness Benefits, Employee St...

3h ago

Go to Apply

Warehouse Associate (days)

Performance Food Group • Fort Worth, TX • 3h ago

Manufacturing & Warehouse

127641BR Job Title: Warehouse Associate (days) Location: CM FortWorth, TX (2572) Job Description: We Deliver the Goods: Competitive pay and benefits, including Day 1 Health & Wellness Benefits, Employee Stock Purchas...

3h 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.