Specialist, Appeals & Grievances
New
M
Molina HealthcareManaged care
Source API remote eligibility restrictions: United States, Monday through Friday, 8:30 AM to 5:00 PM PST; may be required until 5:30 PM PST based on business needsFull-TimeMiddle
Salary not disclosed
Apply NowOpens the employer's application page
Job Details
- Experience
- 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.
- Required Skills
- Microsoft OfficeCustomer service
Requirements
- At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or an 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.
- Knowledge of regulatory guidelines for appeals and denials.
- Customer service experience.
- Strong organizational and time-management skills, including the ability to manage simultaneous tasks and meet internal deadlines.
- Effective verbal and written communication skills.
- Proficiency with Microsoft Office suite or applicable software programs.
- Preferred: Customer/provider experience in a managed care organization, medical office, or hospital setting.
- Preferred: Completion of a healthcare-related vocational program, such as certified coder, billing, or medical assistant.
Responsibilities
- Research and resolve appeals, disputes, grievances, and complaints from members, providers, and outside agencies within internal and regulatory timelines.
- Review claims appeals and grievances using support systems to determine appropriate outcomes.
- Request and review medical records, notes, and detailed bills as appropriate, and formulate conclusions according to protocols and guidelines.
- Apply contract language, benefits, and covered-service reviews to the claims review process.
- Contact members and providers, and prepare appeal summaries and correspondence documenting findings.
- Research claims processing guidelines, provider contracts, fee schedules, and system configurations to identify causes of payment errors.
- Prepare written responses to provider reconsideration requests, claim adjustment requests, and requests from outside agencies.
- Provide telephone, clerical, and data-entry support for the care review team.
- Contact physician offices to request missing authorization information or additional information requested by medical directors.
View Full Description & ApplyYou'll be redirected to the employer's site
