Specialist, Appeals & Grievances (must reside in WI)
Company: Molina Healthcare
Location: Madison
Posted on: May 7, 2024
Job Description:
JOB DESCRIPTION
Job Summary
Responsible for reviewing and resolving member and provider
complaints and communicating resolution to members and provider (or
authorized representatives) in accordance with the standards and
requirements established by the Centers for Medicare and
Medicaid
-
KNOWLEDGE/SKILLS/ABILITIES
- Responsible for the comprehensive research and resolution of
the appeals, dispute, grievances, and/or complaints from Molina
members, providers and related outside agencies to ensure that
internal and/or regulatory timelines are met.
- Research claims appeals and grievances using support systems to
determine appeal 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
Healthcare guidelines.
- Responsible for meeting production standards set by the
department.
- Apply contract language, benefits, and review of covered
services
- Responsible for contacting the member/provider through written
and verbal communication.
- Prepares appeal summaries, correspondence, and document
findings. Include information on trends if requested.
- Composes all correspondence and appeal/dispute and or
grievances information concisely and accurately, in accordance with
regulatory requirements.
- Research claims processing guidelines, provider contracts, fee
schedules and system configurations to determine root cause of
payment error.
- Resolves and prepares written response to incoming provider
reconsideration request is relating to claims payment and requests
for claim adjustments or to requests from outside agencies
-
JOB QUALIFICATIONS
REQUIRED EDUCATION:
High School Diploma or equivalency
REQUIRED EXPERIENCE:
- Min. 2 years operational managed care experience (call center,
appeals or claims environment).
- Health claims processing background, including coordination of
benefits, subrogation, and eligibility criteria.
- Familiarity with Medicaid and Medicare claims denials and
appeals processing, and knowledge of regulatory guidelines for
appeals and denials.
- Strong verbal and written communication skills
-
To all current Molina employees: If you are interested in applying
for this position, please apply through the intranet job
listing.
Molina Healthcare offers a competitive benefits and compensation
package. Molina Healthcare is an Equal Opportunity Employer (EOE)
M/F/D/V.
#PJClaims Pay Range: $14.76 - $31.97 / HOURLY
*Actual compensation may vary from posting based on geographic
location, work experience, education and/or skill level.
Keywords: Molina Healthcare, Dubuque , Specialist, Appeals & Grievances (must reside in WI), Other , Madison, Iowa
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