Specialist, Appeals & Grievances

Molina Healthcare • Arizona, Arizona • 2d 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

Adjudicator, Provider Claims (Must Reside in Ohio)

Molina Healthcare • Tucson, AZ • 32min ago

Finance, Accounting & Banking

Job Description Job Summary The Provider Claims Adjudicator is responsible for responding to providers regarding issues with claims, coordinating, investigates and confirms the appropriate resolution of claims issues. Th...

32min ago

Go to Apply

Adjudicator, Provider Claims (Must Reside in Ohio)

Molina Healthcare • Scottsdale, AZ • 32min ago

Finance, Accounting & Banking

32min ago

Go to Apply

Adjudicator, Provider Claims (Must Reside in Ohio)

Molina Healthcare • Phoenix, AZ • 32min ago

Finance, Accounting & Banking

32min ago

Go to Apply

Adjudicator, Provider Claims (Must Reside in Ohio)

Molina Healthcare • Arizona, Arizona • 33min ago

Finance, Accounting & Banking

33min ago

Go to Apply

Acute Pharmacy Technician

Banner Health • Page, AZ • 33min ago

Hospital & Medical

Primary City/State: Page, Arizona Department Name: Pharmacy-Hosp Work Shift: Varied Job Category: Pharmacy Pharmacy careers are better at Banner Health. We are committed to developing the careers of our team members. We...

33min ago

Go to Apply

Acute Clinical Staff Pharmacist

Banner Health • Chandler, AZ • 36min ago

Hospital & Medical

Primary City/State: Chandler, Arizona Department Name: Pharmacy-Hosp Work Shift: Day Job Category: Pharmacy Innovation and highly trained staff. Our Pharmacy team members play a critical role in ensuring the best care fo...

36min ago

Go to Apply

Activities Assistant - Part Time

Sun Communities • Casa Grande, AZ • 37min ago

Activities Assistant - Part Time Palm Creek Resort & Residences Casa Grande, AZ, US Seasonal Part Time $17 per hour Career Site Header How would you like to work in a fun, fast-paced, and customer-focused role? Do yo...

37min ago

Go to Apply

Adjudicator, Provider Claims (Must Reside in Ohio)

Molina Healthcare • Chandler, AZ • 46min ago

Finance, Accounting & Banking

46min ago

Go to Apply

Adjudicator, Provider Claims (Must Reside in Ohio)

Molina Healthcare • Mesa, AZ • 46min ago

Finance, Accounting & Banking

46min ago

Go to Apply

3D Technical Artist

Dignity Health • Phoenix, AZ • 2h ago

IT & Engineering

Job Summary and Responsibilities The Neuroscience Publications Department at Barrow Neurological Institute leads the academic publishing industry in author services focused entirely on the neurosciences. We provide edito...

2h 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.