Appeals & Grievances Specialist (Complaints & Grievances)

Molina Healthcare • Bellevue, NE • 2d 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

CDL-A Truck Driver - 100% no-touch

Hill Brothers Transportation • Omaha, NE • 4h ago

Trucking & Construction Sponsored

Hiring CDL-A Drivers Job description: Hill Bros. is looking for CDL-A truck drivers in the Midwest with at least one of experience (or recent relevant schooling, see below). We offer high earning potential with lots of b...

4h ago

Go to Apply

Regional CDL A Truck Driver - $6,500 signing bonus

Hill Brothers Transportation • Omaha, NE • 4h ago

Trucking & Construction Sponsored

4h ago

Go to Apply

Wireless Sales Manager - W1637/W4600

OSL Retail Services • Omaha, NE • 9h ago

Management & Administrative

Overview Wireless Manager Are you a dynamic leader with a passion for technology and a track record of driving sales excellence? Welcome to OSL, a vibrant leader in outsourced sales services, proudly partnering with Walm...

9h ago

Go to Apply

Medical Laboratory Scientist Micro

Catholic Health Initiatives • Omaha, NE • 12h ago

Hospital & Medical

Job Summary and Responsibilities Up to $5,000 New Hire Sign-on bonus & up to $10,000 Student Loan Forgiveness* Analyzing lab testing is pretty complex. We depend on the knowledge and skills of our medical technologis...

12h ago

Go to Apply

Medical Laboratory Scientist

Catholic Health Initiatives • Omaha, NE • 13h ago

Hospital & Medical

13h ago

Go to Apply

Loss Prevention Fraud Analyst

U.S. Bank • Omaha, NE • 16h ago

Legal & Paralegal

Spokane, Washington residents: If a street address is not available, enter N/A when completing a job application. At U.S. Bank, we're on a journey to do our best. Helping the customers and businesses we serve to make bet...

16h ago

Go to Apply

Executive Underwriter or AVP, Underwriter Director - Construction Professional Liability

Zurich NA • Omaha, NE • 1d ago

Trucking & Construction

Executive Underwriter or AVP, Underwriter Director - Construction Professional Liability 129449 Zurich is seeking an experienced Executive Underwriter or AVP, Underwriter Director - Construction Professional Liability to...

1d ago

Go to Apply

Customer Service Representative

Waste Connections • Bellevue, NE • 1d ago

Management & Administrative

?? Part-Time Customer Service Representative Location: Bellevue, Nebraska Company: Papillion Sanitation - A Waste Connections Company Pay Range: $18 - $20 per hour Why Choose Waste Connections? At Waste Connections , we...

1d ago

Go to Apply

Manufacturing Associate

Aerotek • Omaha, NE • 1d ago

Manufacturing & Warehouse

Manufacturing Associate Location: Omaha, Nebraska Schedule: Monday-Thursday, 4x10 shifts 1st Shift: 6:00 AM - 4:00 PM - $18.34/hr 2nd Shift: 4:00 PM - 2:00 AM - $19.34/hr We are seeking a reliable and motivated Manufactu...

1d ago

Go to Apply

Immediate Hire - Warehouse Worker

Aerotek • Omaha, NE • 1d ago

Manufacturing & Warehouse

Job Title: Warehouse Worker Job Description We are seeking a dedicated and efficient General Warehouse Worker to join our team. Your primary responsibility will be to ensure the accurate and safe packing of products for...

1d 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.