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Supervisor, Appeals & Grievances

Long Beach, California Job ID 2001533
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Job Description


Job Summary
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

Knowledge/Skills/Abilities
• Supervises staff responsible for the submission/resolution of member inquiries or grievances. Ensures resolutions are compliant.
• Assesses and audits business processes to determine those most effective and efficient at resolving member problems.
• Interfaces with corporate counterparts and member services and ensures standard processes are implemented.
• Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.
• Maintains call tracking system and database of correspondence and outcomes for member appeals; monitors each appeal to ensure all internal and regulatory timelines are met.


Qualifications

Job Qualifications



Required Education
Associate's Degree or 4 years equivalent experience.
Required Experience
• 3 – 4 years experience in claims review and member appeal resolution.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).
Preferred Education
Bachelor's Degree
Preferred Experience
4+ years member resolution experience.
Preferred License, Certification, Association
Certified CPT Coder

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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