Specialist, Appeals & Grievances

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.