Appeals & Grievances Specialist (Complaints & Grievances)

Molina Healthcare • Stamford, CT • 7h ago

JOB DESCRIPTION Job Summary

Provides support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).

Essential Job Duties

Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met.

Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines.

Meets claims production standards set by the department.

Applies contract language, benefits and review of covered services to claims review process.

Contacts members/providers as needed via written and verbal communications.

Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested).

Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements.

Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.

Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies.

Required Qualifications

At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.

Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria.

Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.

Customer service experience.

Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.

Effective verbal and written communication skills.

Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting.

Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $18.04 - $35.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Similar Jobs

Full Stack Developer, Specialist Senior

Deloitte • Stamford, CT • 9min ago

IT & Engineering

Full Stack Developer, Specialist Senior Our Deloitte Customer team empowers organizations to build deeper relationships with customers through innovative strategies, advanced analytics, Generative AI, transformative tech...

9min ago

Go to Apply

Loyalty Management Senior Manager

Deloitte • Stamford, CT • 13min ago

Management & Administrative

Loyalty Management Senior Manager Our Deloitte Customer team empowers organizations to build deeper relationships with customers through innovative strategies, advanced analytics, Generative AI, transformative technologi...

13min ago

Go to Apply

Government Sales Specialist - EAST

Siemens Medical Solutions USA, Inc • Tarrytown, NY • 23min ago

Sales & Marketing

Join us in pioneering breakthroughs in healthcare. For everyone. Everywhere. Sustainably.Our inspiring and caring environment forms a global community that celebrates diversity and individuality. We encourage you to step...

23min ago

Go to Apply

Medical Assistant

Northwell Health • Huntington, NY • 1h ago

Hospital & Medical

Req Number 173567 Job Description Performs patient care under the physician's/nurse's direct supervision. Duties include preparing patient for physician, administering, obtaining and recording diagnostic laboratory test...

1h ago

Go to Apply

Shift Supervisor Trainee

CVS Health • Farmingdale, NY • 2h ago

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...

2h ago

Go to Apply

Senior Analyst, Medical Economics

Molina Healthcare • Yonkers, NY • 2h ago

Hospital & Medical

JOB DESCRIPTION Job Summary Provides senior level analyst support for medical economics analysis activities, including extracting, analyzing and synthesizing data from various sources to identify risks and opportunities,...

2h ago

Go to Apply

Teller I (20 Hours Weekly) Tenafly

TD Bank • Tenafly, NJ • 3h ago

Finance, Accounting & Banking

Work Location: Tenafly, New Jersey, United States of America Hours: 20 Pay Details: - TD is committed to providing fair and equitable compensation opportunities to all colleagues. Growth opportunities and skill developme...

3h ago

Go to Apply

Full Charge Bookkeeper

Robert Half • Eastchester, NY • 3h ago

Finance, Accounting & Banking

Description We are looking for a detail-oriented Part Time Full Charge Bookkeeper to join our team on a contract basis. This position will be REMOTE and will focus on cleaning up and organizing financial records, ensurin...

3h ago

Go to Apply

Marketing Cloud AI Architect - Specialist Master

Deloitte • Stamford, CT • 6h ago

Sales & Marketing

Marketing Cloud AI Architect - Specialist Master Our Deloitte Customer team empowers organizations to build deeper relationships with customers through innovative strategies, advanced analytics, Generative AI, transforma...

6h ago

Go to Apply

Gym Membership Manager!

Anytime Fitness • Pleasantville, NY • 6h ago

Management & Administrative

Do Not Contact the Clubs Our growing Anytime Fitness clubs in Westchester County are adding to the Team the best-of-the-best Gym Managers and Personal Trainers/Coaches. Part Time, or Full Time Available for the right per...

6h 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.