Associate Specialist, Appeals & Grievances (Provider experience)

Job Summary

Responsible for reviewing and resolving member & 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.

Knowledge / Skills / Abilities

Enters denials and requests for appeal into information system and prepares documentation for further review. Research issues utilizing systems and other available resources. Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines. Requests and obtains medical records, notes, and / or detailed bills as appropriate to assist with research. Determines appropriate language for letters and prepare responses to appeals and grievances. Elevates appropriate appeals to the Appeals Specialist. Generates and mails denial letters. Assists with interdepartmental issues to help coordinate problem solving in an efficient and timely manner. Creates and / or maintains statistics and reporting. Works with provider & member services to resolve balance bill issues and other member / provider complaints.

Job Qualifications

High School Diploma or equivalency

1 year of Molina experience, health claims experience, OR one year of customer service / provider service experience in a managed care or healthcare environment. Strong verbal and written communication skills.