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Specialist, Provider Inquiry R&R

Albuquerque, New Mexico Job ID 1903442
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Job Description

Job Summary
Molina Health Plan Operations jobs are responsible for the development and administration of our State health plan's operational departments, programs and services, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations.

Provider Inquiry/Services staff are responsible for the submission, research, and resolution of provider inquiries and/or disputes. They respond with the answer to all incoming inquiries and coordinate with other Molina departments as needed to resolve the issue, as well as to correct the underlying cause, ensuring that resolutions are timely and in compliance with all regulatory requirements.

• Responsible for data collection and analysis regarding provider inquiries and/or disputes.
• Acts as point of contact for submission and/or resolution of denial determinations and practitioner appeals. Interfaces with Provider and/or Member Services regarding reconsiderations, disputes and/or appeals.
• Researches and documents denial determinations at all levels of provider reconsiderations/appeals in a thorough, professional and expedient manner.
• Coordinates workflow between departments and interfaces with internal and external resources.
• Prepares or assists in the preparation of the narratives, graphs, flowcharts, etc. to be utilized for committee presentations and audits.
• Composes all correspondence and appeal information concisely and accurately, in accordance with regulatory requirements.
• Maintains tracking system of correspondence and outcomes; maintains well-organized, accurate and complete files for all appeals.
• Monitors each appeal to ensure all internal and regulatory timelines are met.
• Assists in developing policies, procedures, and quality assurance measures related to provider inquiries/disputes.
• Participates in the provider hearing process as well as alleviates unnecessary hearings through research.


Job Qualifications

Required Education
High School diploma or GED equivalent
Required Experience
3+ years managed care experience; claims review and processing background including coordination of benefits, subrogation, and eligibility criteria.
Required License, Certification, Association
Preferred Education
Associate's Degree in Business and/or completion of a vocational program in Managed Care or some other health care aspect providing a certificate at completion.
Preferred Experience
1+ years provider claims experience.
Preferred License, Certification, Association

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.


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