Healthcare - Appeals Specialist I

Member Complaint Resolution Specialist

Candidates must live in one of the preferred 15 states (AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI) and will be able to work in their own timezone schedule will be Monday to Friday 8AM to 4:30PM.

Job duties include:

• Research member complaints
• Update system to reflect research completed
• Resolve member complaints within the timeframe

Knowledge/Skills/Abilities:

• Comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies
• Research claims appeals and grievances using support systems to determine outcomes
• Request and review medical records, notes, and/or detailed bills as appropriate
• Formulate conclusions per protocol and other business partners to determine response
• Meet production standards set by the department
• Apply contract language, benefits, and review of covered services
• Contact the member/provider through written and verbal communication
• Prepare appeal summaries, correspondence, and document findings
• Compose all correspondence and appeal/dispute and/or grievances information concisely and accurately
• Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine root cause of payment error
• Resolve and prepare written response to incoming provider reconsideration request relating to claims payment and requests for claim adjustments or to requests from outside agencies

Job qualifications required:

• High School Diploma or equivalency
• Minimum 2 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