Specialist, Appeals & Grievances

Molina Healthcare • Madison, WI • 19h 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

Director, Total Rewards

Wipfli LLP • Madison, WI • 2h ago

Overview At Wipfli, people count At Wipfli, our people are core to everything we do-the catalyst behind our ability to create exceptional impact and extraordinary results. We believe in flexibility. We focus on relations...

2h ago

Go to Apply

Hardware Developer 4 (Sustaining Engineer)

Oracle • Madison, WI • 10h ago

IT & Engineering

Job Description Oracle's West Coast Hardware Development organization is seeking an experienced Senior Hardware Sustaining Engineer to join our collaborative teams in Santa Clara, California. In this role, you'll play a...

10h ago

Go to Apply

ServiceNow Solution Sales Executive

NTT America, Inc. • Madison, WI • 16h ago

Management & Administrative

Unleash Your Potential: Whether 2 Years or 20, Discover Rewarding Journeys with Us! We are seeking a dynamic and experienced ServiceNow Solution Sales Executive to lead go-to-market activities focused on expanding Servic...

16h ago

Go to Apply

Director, Software Engineering

Oracle • Madison, WI • 17h ago

IT & Engineering

Job Description Lead, mentor, and manage a team of engineers focused on software development, operations, and distributed systems. Oversee the design, development, testing, debugging, and deployment of software applicati...

17h ago

Go to Apply

Principal Software Engineer - AI & ML Innovation

Oracle • Madison, WI • 17h ago

IT & Engineering

Job Description The Senior Principal AI/ML Software Engineer is responsible for evaluating, integrating, and optimizing cutting-edge technologies for AI/ML infrastructure, focusing on achieving low latency, high throughp...

17h ago

Go to Apply

Senior Software Engineer, Search Perform

CRIBL INC • Madison, WI • 17h ago

IT & Engineering

JOB REQUIREMENTS: Number of Openings: 1 Job Title: Senior Software Engineer, Search Performance (Backend) Occupational Category: Please choose the most appropriate choice based on the Job Title and Description. Duties an...

17h ago

Go to Apply

Home Daily Truck Driver

Roehl Transport • Lake Mills, WI • 21h ago

Trucking & Construction

Be home every day in Beaver Dam! Pay is a combination of mileage pay and activity pay. You will drive mostly Monday (start at 0200) through Friday evening. You will work 12-14 hours a day in this dedicated position. You'...

21h ago

Go to Apply

Home Daily Truck Driver

Roehl Transport • Sun Prairie, WI • 21h ago

Trucking & Construction

21h ago

Go to Apply

CDL-A - Dedicated truck driver - Toro

Schneider • Madison, WI • 21h ago

Trucking & Construction

Dedicated truck driver - Toro Average pay: $1,020-$1,250 weekly Home time: Weekly Experience: All CDL holders Overview Haul 100% no-touch lawn and garden freight in dry van trailers. 75% drop-and-hook. 5-10 loads per wee...

21h ago

Go to Apply

Bilingual Lead Medical Coordinator_JOR

National Youth Advocate Program • Madison, WI • 1d ago

Hospital & Medical

Working At NYAP NYAP's commitment to doing what is best for children, youth and their families is a core value and one that we look for in our newest team members. 33 Paid days off each year!?(11 holidays + 22 days PTO)...

1d 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.