Associate Specialist, Appeals & Grievances
New
Remote TXFull-TimeEntry
Salary not disclosed
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Job Details
- Experience
- At least 1 year
- Required Skills
- Microsoft Office
Requirements
- At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting, or equivalent combination of relevant education and experience.
- Customer service experience.
- 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: Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting experience.
- Preferred: Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant).
Responsibilities
- Review and resolve member and provider complaints.
- Communicate resolution to members or authorized representatives in accordance with CMS standards.
- Enter denials and requests for appeals into information system and prepare documentation.
- Research claims issues utilizing systems and other available resources.
- Assure timeliness and appropriateness of appeals according to state, federal and Molina guidelines.
- Request and obtain medical records, notes, and/or detailed bills as appropriate.
- Determine appropriate language for letters and prepare responses to member appeals and grievances.
- Elevate appropriate appeals to the next level for review.
- Generate and mail denial letters.
- Provide support for interdepartmental issues to coordinate problem-solving.
- Create and/or maintain appeals and grievances related statistics and reporting.
- Collaborate with provider and member services to resolve balance bill issues and other complaints.
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