Rep, Provider Inquiry R&RLong Beach, California Job ID 1903741
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.
• 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.
High School diploma or GED equivalent
3 years experience in a managed care setting; CPT and ICD-9 coding, data entry, and 10-Key experience.
Required License, Certification, Association
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.
4+ years managed care 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.