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Appeals & Grievances Health Claims Processing

3 months ago

Long Beach, United States OMG Technology Full time

**_Appeals & Grievances Health Claims Processing Specialist (REMOTE)_**Position Summary**:
Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and providers (or authorized representatives) following the standards and requirements established by the Centers for Medicare and Medicaid.

**Position Responsibilities**:

- Complete Acknowledgement letters.
- Triage appeal cases, classify appeal type.
- Responsible for the comprehensive research and resolution of the appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met.
- Research 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 the 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 documents findings. Include information on trends if requested.
- Composes all correspondence and appeal/dispute and or grievance information concisely and accurately, following regulatory requirements.
- Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine the root cause of payment errors.
- Resolves and prepares written responses to incoming provider reconsideration requests relating to claims payment and requests for claim adjustments or to requests from outside agencies.

**Required Skills/Experience/Education**:

- At least 4+ years of **operational managed care experience **(call center, appeals, or claims environment).
- Experience working in** Appeals & Grievances**.
- Experience with **health claims processing background**, including **coordination of benefits, subrogation, **and **eligibility criteria.**
- Familiarity with **Medicaid and Medicare claims denials and appeals processing**.
- Knowledge of regulatory guidelines for appeals and denials.
- Ability to prioritize, work in a fast-paced environment, work independently, as well as with a team.
- Strong verbal and written communication skills.
- High School Diploma or equivalency.
- **Equipment Provided**:this role will require 2 Monitors, a computer/laptop, a mouse, a keyboard, and a headset.

**Other job specifications**:

- ** Employment Type**:Contract to Hire (CTH), **W2 only. NO C2C.**:

- **Contracting Period**: 6-month contracting opportunity with the possibility of extension, and Temp to Perm hire opportunity.
- **Contract Rate/Salary**:$21/hr. on W2.
- **Interview Process**: Microsoft Teams Meeting (1 interview).