Specialist, Appeals & Grievances
On-siteTexas, United States
Job Summary
Facilitate comprehensive research and resolution of appeals, disputes, grievances, and complaints from Molina members, providers, and outside agencies while adhering to CMS and state guidelines. Review medical records, notes, and bills to formulate conclusions, then compose correspondence and appeal summaries that document findings and track trends. Contact members and providers via written and verbal channels to communicate resolution outcomes. Apply contract language, benefits, and covered services to the claims review process, ensuring all responses meet internal and regulatory timelines. Requires at least two years of managed care experience, proficiency in Microsoft Office, and strong organizational skills. Full-time role with competitive compensation and benefits.
Required Qualifications
- At least 2 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 processing, and knowledge of regulatory guidelines for appeals and denials
- Customer service experience
- Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines
- Effective verbal and written communication skills
- Microsoft Office suite/applicable software program(s) proficiency
Desired Qualifications
- Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting
- Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant)
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