Specialist, Appeals & Grievances Medicaid

New

Molina HealthcareManaged care

United States, CST HoursFull-TimeMiddle

Salary not disclosed

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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

Have 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.
Have health claims processing experience, including coordination of benefits (COB), subrogation, and eligibility criteria.
Have experience processing Medicaid and Medicare claims denials and appeals.
Know regulatory guidelines for appeals and denials.
Have customer service experience.
Demonstrate strong organizational and time-management skills and the ability to manage simultaneous projects and tasks to meet internal deadlines.
Have effective verbal and written communication skills.
Be proficient with Microsoft Office suite or applicable software programs.
Preferred: Have customer or provider experience in a managed care organization, medical office, or hospital setting.
Preferred: Have completed a healthcare-related vocational program, such as certified coding, billing, or medical assistant training.

Research and resolve appeals, disputes, grievances, and complaints from members, providers, and outside agencies within internal and regulatory timelines.
Use support systems to research claims appeals and grievances and determine appropriate outcomes.
Request and review medical records, notes, and detailed bills as appropriate, and formulate conclusions according to protocol.
Apply contract language, benefits, and covered-service reviews to the claims review process.
Contact members and providers as needed through written and verbal communications.
Prepare appeal summaries and correspondence, and document findings and trends as requested.
Compose accurate correspondence and information about appeals, disputes, and grievances in accordance with regulatory requirements.
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.

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