Lead, Appeals & GrievancesMolina Healthcare Las Vegas, Nevada Job ID 2011002
Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid and the State regulatory agencies.
- Serves as team lead for a small group of employees responsible for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members and related outside agencies.
- Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.
- Researches issues utilizing systems and clinical assessment skills, knowledge and approved “Decision Support Tools” in the decision making process regarding health care services and care provided to members.
- Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines.
- Prepares appeal summaries, correspondence and documents information for tracking/trending data.
- Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits.
Associate's or bachelor’s degree or equivalent years of experience in related field.
- Min. 3 years of experience analyzing, and rectifying member appeals and grievances and 2 years managed care experience.
- Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.
Associate's or bachelor’s degree
Experience in managed care compliance.
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
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.Job Type: Full Time Posting Date: 12/15/2021
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