Specialist, Appeals & Grievances; Reside in OH or KY

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Provides support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with standards and requirements established by Centers Medicare and Medicaid Services (CMS).

• Facilitates comprehensive research and resolution w appeals disputes grievances and/or complaint from Molina members providers and related outside agencies to ensure internal regulatory timelines met.
• Researches claims appeals and grievances using support system determine appropriate appeals and grievance outcomes.
• Requests and reviews medical records notes and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners determine response; assures timeliness and appropriateness responses per state federal and Molina guidelines.
• Meets claims production standards set by department.
• Applies contract language benefits and review of covered services to claims review process.
• Contacts members/providers needed via written verbal communications.
• Prepares appeal summaries and correspondence and documents findings accordingly includes information trends as requested.
• Composes all correspondence appeals/disputes and/or grievances information concisely accurately in accordance with regulatory requirements.
• Researches claims processing guidelines provider contracts fee schedules and systems configurations to determine root causes payment errors.
• Resolves and prepares written response incoming provider reconsideration requests related claims payment requests for claim adjustments and/or requests from outside agencies.

• At least 2 years managed care experience call center appeals and/or claims environment equivalent combination relevant education experience.
• Health claims processing experience including coordination benefits (COB) subrogation eligibility criteria.
• Experience Medicaid Medicare claims denials and appeals processing and knowledge regulatory guidelines appeals and denials.
• Customer service experience.
• Strong organizational time management skills ability manage simultaneous projects tasks meet internal deadlines.
• Effective verbal written communication skills.
• Microsoft Office suite applicable software program proficiency.

• Customer/provider experience managed care organization Medicaid Medicare Marketplace and/or other government sponsored program medical office hospital setting.
• Completion health care related vocational program health care (i.e certified coder billing or medical assistant).

Molina Healthcare offers competitive benefits compensation package Molina Healthcare Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $16.4 - $31.97 / HOURLY

* Actual compensation may vary from posting based geographic location work experience education and/or skill level.