Specialist, Appeals & Grievances

Molina Healthcare • Ohio, Ohio • 5h 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

Sales Specialist NF2 Flexible

U.S. Marine Corps • Virginia, Virginia • 1h ago

Sales & Marketing

Summary Marine Corps Community Services (MCCS) is looking for the best and brightest to join our Team! MCCS is a comprehensive program that supports and enhances the quality of life for Marines, their families, and other...

1h ago

Go to Apply

MEATCUTTING WORKER

Defense Commissary Agency • Wyoming, Wyoming • 3h ago

Summary Meatcutting Workers assist full performance meatcutters by performing simpler tasks when processing beef, pork, veal, and lamb into retail and ready to eat cuts for sale to patrons. Specific assignments vary by i...

3h ago

Go to Apply

Specialist, Appeals & Grievances

Molina Healthcare • Michigan, Michigan • 5h 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...

5h ago

Go to Apply

Senior Medical Director

Molina Healthcare • Ohio, Ohio • 5h ago

Hospital & Medical

JOB DESCRIPTION Job SummaryLeads and manages a team of medical directors delivering oversight and expertise in appropriateness and medical necessity of services provided to members - ensuring members receive the most app...

5h ago

Go to Apply

Senior Medical Director

Molina Healthcare • Michigan, Michigan • 5h ago

Hospital & Medical

5h ago

Go to Apply

DMO Enterprise Programmer

SAIC • California, California • 10h ago

IT & Engineering

Description PURPOSE : Provide Technical Support Services to USAF DMO Enterprise JOB DESCRIPTION: USAF Training Centers require DMO scheduling assistance to develop an ECS-like AF Enterprise scheduling system and to maxim...

10h ago

Go to Apply

AI Solutions Engineering Delivery Lead

PwC • California, California • 10h ago

Retail & Hospitality

Specialty/Competency: IFS - Internal Firm Services - Other Industry/Sector: Not Applicable Time Type: Full time Travel Requirements: Up to 20% At PwC, our people in data and analytics engineering focus on leveraging adva...

10h ago

Go to Apply

AVP, Vendor Management - REMOTE

Molina Healthcare • Michigan, Michigan • 10h ago

Management & Administrative

JOB DESCRIPTION Job Summary Provides strategy and leadership to teams responsible for enterprise-wide vendor management activities - ensuring comprehensive operational efficiency, functional leadership engagement, sustai...

10h ago

Go to Apply

AVP, Vendor Management - REMOTE

Molina Healthcare • Ohio, Ohio • 10h ago

Management & Administrative

10h ago

Go to Apply

Project Executive - Data Center

Cupertino Electric • Ohio, Ohio • 10h ago

IT & Engineering

Posting Title: Project Executive - Data Center Construction Reports To: Vice President Operations - Data Center Location: Ohio, Wisconsin, Iowa, New Mexico, Utah, Nevada, Washington, and California Salary Range: $150,000...

10h 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.