Other Service Line - BPO TeamLead Operations - OPTLOP

Provider Specialist

MAX VENDOR RATE $23.50 REMOTE

Responsible for reviewing and resolving provider disputes and communicating resolution to provider in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

Job Responsibilities:

• Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina 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 protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines.
• 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.
• Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies.

Top Skills:

• Provider Appeals and Grievance on the insurance side of the business
• Claims review/processing/billing&coding experience
• Healthcare Insurance Customer Service experience

Additional Information:

Monday-Friday 8 am 4:30 pm EST

The team is supported by multiple specialists who assist with onboarding and questions. There are 2 team huddles a week for announcements and check ins as well as team building activities 2 times a month. Training is 4 to 6 weeks in which 100% attendance is REQUIRED. The associate will then have a ramp up period of 8 weeks to meet their expected metrics.