Lead Spec, Appeals

3 weeks ago

Long Beach, United States Molina Healthcare Full time

Job Summary

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for 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

KNOWLEDGE/SKILLS/ABILITIES

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, providers and related outside agencies.

Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.

Research and resolves escalated issues including state complaints and high visible, complex cases.

Assign work to team.

Prepares appeal summaries, correspondence, and documents information for tracking/trending data.

Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits. Researches claims appeals and grievances using support systems to determine appeal 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 Healthcare guidelines.

Responsible for meeting production standards set by the department.

Responsible for contacting the member/provider through written and verbal communication.

Prepares appeal summaries, correspondence, and document findings.

Include information on trends if requested.

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

Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error (provider).

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 (Providers)

JOB QUALIFICATIONS

**REQUIRED EDUCATION**:
High School Diploma or equivalency

**REQUIRED EXPERIENCE**:
Min. 3 years operational managed care experience (call center, appeals or claims environment).

Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.

Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.

Strong verbal and written communication skills

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

PJClaims
**Pay Range**: $17.85 - $38.69 / HOURLY
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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