Appeals & Grievances Specialist (Complaints & Grievances)

Molina Healthcare • Madison, WI • 15h 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

Registered Nurse - Triage

ACCESS COMMUNITY HEALTH CENTERS • Madison, WI • 52min ago

Hospital & Medical

JOB REQUIREMENTS: Access Community Health Centers, Inc Registered Nurse - Triage Regular Full-Time Registered Nurse - Triage Position Summary: The Registered Nurse (RN) works collaboratively as an active member of the in...

52min ago

Go to Apply

Inside Sales Rep - Automotive (Remote)

Concentrix • Madison, WI • 1h ago

Sales & Marketing

Home ( https://jobs.concentrix.com/ ) »Job Details Inside Sales Rep - Automotive (Remote) Operations ( https://jobs.concentrix.com/job-search/?category=Operations ) Location United States Of America Language English Appl...

1h ago

Go to Apply

Specialist, Renewal Sales

Concentrix • Madison, WI • 6h ago

Sales & Marketing

Home ( https://jobs.concentrix.com/ ) »Job Details Specialist, Renewal Sales Operations Other Location United States Of America Language English Apply Now ( https://cnx.wd1.myworkdayjobs.com/external\global/job/USA-Work-...

6h ago

Go to Apply

Professional I, Lead Generation

Concentrix • Madison, WI • 6h ago

Home ( https://jobs.concentrix.com/ ) »Job Details Professional I, Lead Generation Marketing & Communications Account Management Location United States Of America Language English Apply Now ( https://cnx.wd1.myworkda...

6h ago

Go to Apply

Sr. Data Engineer

CVS Health • Madison, WI • 8h ago

IT & Engineering

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...

8h ago

Go to Apply

Senior Analyst, Medical Economics

Molina Healthcare • Madison, WI • 10h 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,...

10h ago

Go to Apply

Residential Lending Loan Officer Associate

City National Bank • Madison, WI • 11h ago

Finance, Accounting & Banking

RESIDENTIAL LENDING LOAN OFFICER ASSOCIATE WHAT IS THE OPPORTUNITY? Provide support to one or more Residential Loan Officer to facilitate the timely review and submission of completed mortgage loan application packages,...

11h ago

Go to Apply

Tree Climber - Crew Leader

SavATree • Madison, WI • 11h ago

JOB REQUIREMENTS: Number of Openings: 1 Job Title: Tree Climber - Crew Leader Occupational Category: Please choose the most appropriate choice based on the Job Title and Description. Duties and Responsibilties of Job: Lo...

11h ago

Go to Apply

Tree Climber-Tree Care

SavATree • Madison, WI • 11h ago

JOB REQUIREMENTS: Number of Openings: 1 Job Title: Tree Climber-Tree Care Occupational Category: Please choose the most appropriate choice based on the Job Title and Description. Duties and Responsibilties of Job: Locati...

11h ago

Go to Apply

Electrical Project Manager - Mission Critical

Eaton Corporation • Madison, WI • 15h ago

Management & Administrative

Eaton's ES AMER ESS division is currently seeking a Electrical Project Manager - Mission Critical. This position is fully remote with up to 50% travel. The expected annual salary range for this role is $93750.03 - $13750...

15h 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.