Specialist, Appeals & Grievances

Molina Healthcare • Provo, UT • 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

Specialist, Social Media Marketing

Qualtrics • Provo, UT • 2h ago

Sales & Marketing

At Qualtrics, we create software the world's best brands use to deliver exceptional frontline experiences, build high-performing teams, and design products people love. But we are more than a platform-we are the creators...

2h ago

Go to Apply

CDL-A - Over-the-Road (OTR) Van Truckload truck driver - 48 states

Schneider • Provo, UT • 6h ago

Trucking & Construction

Over-the-Road (OTR) Van Truckload truck driver - 48 states Average pay: $1,115-$1,360 weekly Home time: Monthly Experience: All CDL holders Overview Predictable power lanes with a high volume of freight. Consistent freig...

6h ago

Go to Apply

Accounts Payable Supervisor

Vivint • Lehi, UT • 9h ago

Finance, Accounting & Banking

Welcome to the intersection of energy and home services. At NRG, we're driven by our passion to create a smarter, cleaner and more connected future. Vivint Smart Home, an NRG owned company, is a leading smart home compan...

9h ago

Go to Apply

Manager in Training - (Path to GM $70-$80K) - Let's Play Soccer

Let's Play Sports • Lindon, UT • 21h ago

Management & Administrative

Manager in Training - Career Path to General Manager ($70K-$80K) - Let's Play Soccer, Lindon Let's Play Soccer - The Indoor Soccer Company Our Mission: Uniting people for the love of the Beautiful Game. We make a positiv...

21h ago

Go to Apply

Industrial Maintenance Mechanic/Welder

MCWANE DUCTILE - UTAH • Provo, UT • 1d ago

Legal & Paralegal

Company Description About Us: McWane Ductile stands today as North America's leading and most experienced ductile iron pipe manufacturer and supplier. Building iron strong utilities for generations since 1926, we are a f...

1d ago

Go to Apply

Senior Medical Director

Molina Healthcare • Orem, UT • 1d 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...

1d ago

Go to Apply

Senior Medical Director

Molina Healthcare • Provo, UT • 1d ago

Hospital & Medical

1d ago

Go to Apply