Specialist, Appeals & Grievances

Molina Healthcare • New York, New York • 1h 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

Sr. Associate, Product Management, Card Intelligence (Acquisitions)

Capital One • New York, NY • 7min ago

Management & Administrative

Sr. Associate, Product Management, Card Intelligence (Acquisitions) Product Management Are you passionate about leveraging cutting-edge machine learning solutions to drive innovation in the financial services industry? I...

7min ago

Go to Apply

Sr. Associate, Product Management, Card Intelligence (Acquisitions)

Capital One Services, LLC • New York, NY • 10min ago

Management & Administrative

Sr. Associate, Product Management, Card Intelligence (Acquisitions) Product ManagementAre you passionate about leveraging cutting-edge machine learning solutions to drive innovation in the financial services industry? In...

10min ago

Go to Apply

Sr. Lead AI Engineer

Capital One • New York, NY • 15min ago

IT & Engineering

Sr. Lead AI Engineer Overview: At Capital One, we are creating responsible and reliable AI systems, changing banking for good. For years, Capital One has been an industry leader in using machine learning to create real-t...

15min ago

Go to Apply

Machine Learning Scientist - Natural Language Processing (NLP) - Vice President - Machine Learning Center of Excellence

JPMorgan Chase • New York, NY • 16min ago

Management & Administrative

At JPMorgan Chase, AI and technology promote our global operations with unmatched scale and speed. We invest over $18 billion annually in innovation, data leverage, and security to shape the future for our clients, commu...

16min ago

Go to Apply

Radiology Scheduler

Memorial Sloan-Kettering Cancer Center • New York, NY • 18min ago

Hospital & Medical

About Us: The people of Memorial Sloan Kettering Cancer Center (MSK) are united by a singular mission: ending cancer for life. Our specialized care teams provide personalized, compassionate, expert care to patients of al...

18min ago

Go to Apply

Informatics Analyst, Division Management & Systems Coordination

City of New York • New York, NY • 19min ago

Management & Administrative

Job Description The Division of Disease Control's mission is to safeguard the health of New Yorkers through identification, surveillance, treatment, control, and prevention of infectious diseases, which is achieved throu...

19min ago

Go to Apply

Head of Data Strategy - Asset Management Operations

JPMorgan Chase • New York, NY • 1h ago

Management & Administrative

As the Head of AM Operations Data Strategy, you will be responsible for defining and executing a comprehensive strategy for the development, governance, and delivery of data across Asset Management Operations, with a par...

1h ago

Go to Apply

Senior Medical Director

Molina Healthcare • New York, New York • 1h 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...

1h ago

Go to Apply

Operations Manager

CVS Health • New York, NY • 1h ago

Management & Administrative

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions compan...

1h ago

Go to Apply

Senior Medical Director

Molina Healthcare • Yonkers, NY • 2h ago

Hospital & Medical

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.