Senior Specialist, Appeals & Grievances

JOB DESCRIPTION:

Provides senior level support for activities including reviewing and resolving member and provider complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).

Essential Job Duties

• Provides senior level support for comprehensive research and resolution of complex, escalated and high dollar appeals, grievances, and/or complaints from Molina members, providers and related outside agencies.

• Research appeals and grievances using support systems to determine appeals and grievance outcomes.

• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines.

• Meets production standards set by the department.

• Applies contract language, benefits, and review of covered services.

• Contacts members/providers via written and verbal communications as needed.

• Prepares summaries and correspondence, and documents findings accordingly.

• Identifies trends and operational deficiencies discovered in complaints.

• Composes all correspondence, and/or grievances information concisely and accurately, and in accordance with regulatory requirements.

• Resolves and prepares written responses to incoming members and providers, and from outside agencies. 

Required Qualifications

• 3 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.

 Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria.

• Experience with Medicaid and Medicare claims denials and appeals and grievance processing, and knowledge of regulatory guidelines for appeals and denials. 
• Strong customer service experience.  
• Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.
• PEGA
• Salesforce
• QNXT

Preferred Qualifications

• Customer/provider experience in a managed care organization (Medicaid, Medicare, and/or other government-sponsored program), or medical office/hospital setting.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $16.23 - $35.17 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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. Remote positions are U.S.-based only. Candidates must reside and be authorized to work in the United States. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.