Member Appeals & Grievances Specialist - Remote EST

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Molina Healthcare is hiring for an Appeals & Grievance Specialist. This role is remote and will be working an Eastern Time Zone schedule.

The Appeals & Grievance Specialist will be responsible for reviewing and resolving member disputes/complaints and communicating resolution to members 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
  
  

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.

Pay Range: $21.16 - $38.37 / HOURLY

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

If you have questions about this posting, please contact [email protected]