Appeals Grievances Specialist (Complaints Grievances)

divh2Job Summary/h2pProvides 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)./ph3Essential Job Duties/h3ulliFacilitates 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./liliResearches claims appeals and grievances using support systems to determine appropriate appeals and grievance outcomes./liliRequests 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./liliMeets claims production standards set by the department./liliApplies contract language, benefits and review of covered services to claims review process./liliContacts members/providers as needed via written and verbal communications./liliPrepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested)./liliComposes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements./liliResearches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors./liliResolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies./li/ulh3Required Qualifications/h3ulliAt least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience./liliHealth claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria./liliExperience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials./liliCustomer service experience./liliStrong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines./liliEffective verbal and written communication skills./liliMicrosoft Office suite/applicable software program(s) proficiency./li/ulh3Preferred Qualifications/h3ulliCustomer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting./liliCompletion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant)./li/ulpTo all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board./ppMolina 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./p/div