Appeals & Grievances Specialist (PST Time Zone Remote)

Remote StaffingRochester, NY, US

1 day ago

Job type

Full-time

Remote

Job description

Appeals & Grievance Specialist

Molina Healthcare is hiring for an Appeals & Grievance Specialist. This role is 100% remote and will work in the Pacific Time Zone. This role provides support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). Highly qualified applicants will have the following experience :

Call center experience
Familiarity with claims
Great computer and MS Office skills
Great communication both written and verbal

Essential job duties :

Facilitates comprehensive research and resolution of appeals, disputes, grievances, and / or complaints from Molina members, providers, and related outside agencies to ensure that internal and / or regulatory timelines are met.

Researches claims appeals and grievances using support systems to 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 to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines.

Meets claims production standards set by the department.

Applies contract language, benefits and review of covered services to claims review process.

Contacts members / providers as needed via written and verbal communications.

Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested).

Composes all correspondence, appeals / disputes and / or grievances information concisely, accurately and in accordance with regulatory requirements.

Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.

Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and / or requests from outside agencies.

Required qualifications :

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.

Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria.

Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.

Customer service experience.

Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.

Effective verbal and written communication skills.

Microsoft Office suite / applicable software program(s) proficiency.

Preferred qualifications :

Customer / provider experience in a managed care organization (Medicaid, Medicare, Marketplace and / or other government-sponsored program), or medical office / hospital setting.

Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).

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.

Create a job alert for this search

Pst • Rochester, NY, US

Related jobs

Promoted

Travel Physical Therapist - $2,700 per week

CompHealth Inc.Webster, NY, United States

Permanent

Physical Therapist for a travel job in Webster, New York.Job Description & Requirements.Though your CompHealth recruiter will be your single point of contact, they are backed by dozens of specializ...Show moreLast updated: 30+ days ago

Promoted

Travel Physical Therapist (PT) - $1,820 to $3,000 per week in Webster, NY

AlliedTravelCareersWebster, NY, US

Full-time

AlliedTravelCareers is working with CompHealth to find a qualified Physical Therapist (PT) in Webster, New York, 14560!.CompHealth services are always free to you. Let us do the heavy lifting and ha...Show moreLast updated: 3 days ago

Promoted

Drive with DoorDash - Sign Up in Minutes

DoorDashPrattsburgh, NY, United States

Full-time +1

DoorDash is the #1 category leader in food delivery, food pickup, and convenience store delivery in the US, trusted by millions of customers every day. As a Dasher, you’ll stay busy with a variety o...Show moreLast updated: 3 days ago

Promoted

Special Agent, $40,000 Recruitment Incentive

The United States Secret ServiceOntario, NY, United States

Full-time

Recruitment Incentive : Applicants may be eligible for a $40,000 recruitment incentive in accordance with regulatory requirements. Click apply for complete details on the recruitment incentive detail...Show moreLast updated: 30+ days ago

Promoted

Hiring Now - Work from Home - No Experience

OCPAWebster town, New York, us

Remote

Part-time +1

Product Testers are wanted to work from home nationwide in the US to fulfill upcoming contracts with national and international companies. We guarantee 15-25 hours per week with an hourly pay of bet...Show moreLast updated: 30+ days ago

Promoted

Flexible Remote Work – Get Paid to Share Your Opinions on Top Brands

OCPACohocton town, New York, us

Remote

Part-time +1

Promoted

Part Time - Work from Home - Online Product Tester - No experience ($25-$45 per hour)

OCPARushville, New York, us

Remote

Part-time +1

Promoted

Travel CT Tech - $1,663 to $1,859 per week in Gainesville, CT

AlliedTravelCareersGainesville, CT, US

Full-time

AlliedTravelCareers is working with Prime Time Healthcare to find a qualified CT Tech in Gainesville, Connecticut!.Now Hiring : Allied Healthcare CT - Gainesville, Florida.Contact us for Pay Informa...Show moreLast updated: 26 days ago

Promoted

Drive with DoorDash - Flexible Schedule

DoorDashPrattsburgh, NY, United States

Full-time +1

Promoted

Remote Options Trading Job in Rochester, NY | Part Time

Maverick TradingRochester, NY, USA

Remote

Part-time

Remote Options Trader Position at Maverick Trading.Maverick Trading is a proven proprietary trading firm with more than 26 years of market expertise. We empower traders with access to firm capital w...Show moreLast updated: 30+ days ago

Promoted

Border Patrol Agent - Earn up to $30,000 in Recruitment Incentives

U.S. Customs and Border ProtectionRushville, NY, US

Full-time

Customs and Border Protection (CBP) offers those interested in a career in law enforcement an exceptional opportunity to work with an elite team of highly trained professionals whose camaraderie, p...Show moreLast updated: 1 day ago

Promoted

Remote Options Trading Job in Rochester, NY | Part Time

Maverick CurrenciesRochester, NY

Remote

Part-time

Empowering Traders to Achieve Financial Freedom.Apex Trading Solutions has been at the forefront of proprietary trading for over two decades. We are looking for motivated traders eager to grow, lear...Show moreLast updated: 23 days ago

Promoted

Remote Online Survey Taker – Earn Up to $25 Per Survey

Earn HausIrondequoit, NY, US

Remote

Full-time +1

We are urgently looking for people interested in taking online surveys for Fortune 500 brands.If you are a self-starter, looking for flexible hours throughout the week, this may be for you! Earn up...Show moreLast updated: 3 days ago

Promoted

Associate Specialist, Appeals & Grievances - Remote

Remote StaffingRochester, NY, US

Remote

Full-time

Provides entry level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accorda...Show moreLast updated: 1 day ago

Promoted

Remote Part-Time Survey Job – No Experience Needed, Up to $25 Each

Earn HausGreece, NY, US

Remote

Full-time +1

Promoted

Remote Prop Trading Job in Rochester, NY | Part Time

Maverick CurrenciesRochester, NY

Remote

Part-time

Promoted

Reserve Entomologist

United States ArmyLe Roy, New York, United States

Full-time

THE ARMY HEALTH CARE ADVANTAGE As a member of the Army health care team, you’ll receive benefits that you won’t be able to get in a civilian career. Challenging Work Feel inspired with great case di...Show moreLast updated: 1 day ago

Promoted

Travel Physical Therapist - $1,950 per week

Uniti MedWebster, NY, United States

Full-time

Uniti Med is seeking a travel Physical Therapist for a travel job in Webster, New York.Job Description & Requirements.Cigna medical, MetLife dental and vision insurance . License reimbursement for n...Show moreLast updated: 1 day ago