Rep, Provider Inquiry R&R - Location Columbus, OH, or Louisville, KY,

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.

KNOWLEDGE/SKILLS/ABILITIES

• Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment and requests for claim adjustments or to requests from outside agencies.
• Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
• Identifies potential provider problems through a proactive approach in which data is mined and trended to identify and prevent provider problem areas.
• Uses a variety of references to research and prepare healthcare provider information for loading into the health plan system/database; enters provider demographics, contract affiliation, or other data as needed.
• Interfaces with other departments regarding questions about provider configuration or other relevant provider issues.
• 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 request to ensure all internal and regulatory timelines are met.

JOB QUALIFICATIONS

Required Education

High School diploma or GED equivalent

Required Experience

3 years’ experience in a managed care setting; CPT and ICD-9 coding, data entry, and 10-Key experience.

Preferred Education

Associate 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

4+ years managed care experience.

Preferred License, Certification, Association

CPC certification

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.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.