Apply on Employer Site

Molina Healthcare · 12 hours ago

Lead Specialist, Appeals & Grievances

United States

Full-time

Remote

Mid, Senior Level

$21.65/hr - $46.42/hr

3+ years exp

Molina Healthcare is a company that provides managed care services, and they are seeking a Lead Specialist in Appeals & Grievances. This role involves leading the resolution of member and provider complaints, training new employees, and ensuring compliance with regulatory standards.

Health CareHospitalMedical

Responsibilities

Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies

Trains new employees and provides guidance to others with respect to complex appeals and grievances

Researches and resolves escalated issues including state complaints and high visible complex cases

In conjunction with claims leadership, assigns claims work to team

Prepares appeal summaries and correspondence, and documents information for tracking/trending data

Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances 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

Contacts members/providers via written and verbal communications as needed

Prepares appeal summaries and correspondence and documents findings; includes information on trends if requested

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

Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment errors

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

Qualification

Managed care experienceHealth claims processingMedicaidMedicare knowledgeCustomer service experienceOrganizational skillsVerbal communication skillsWritten communication skillsMicrosoft Office proficiencyTraining skillsTime management skills

Required

At least 3 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, subrogation and eligibility criteria

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

Strong customer service experience

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

Strong verbal and written communication skills

Microsoft Office suite/applicable software program(s) proficiency

Preferred

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)