Appeals Specialist I

Appeals Specialist I

Will the position be 100% remote? Yes- please source candidates from any one of the following 15 states: AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI. Are there any time zone requirements? Any time zone. What are the must have requirements? Dependability, good grammar skills, good phone communication skills, and meet the description in the job chosen (Appeals Specialist I). What are the day to day responsibilities? Research and respond to Medicare grievances in accordance with CMS regulations (training will be provided). Is there specific licensure required in order to qualify for the role? No. What is the desired work hours (i.e. 8am – 5pm) 8 a.m. to 5 p.m. in their time zone. Please clearly indicate on resume their City and State. Will need dual monitors and a docking station- price not to exceed $350.

Job Summary: Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

KNOWLEDGE/SKILLS/ABILITIES:

• Responsible for the comprehensive research and resolution of the appeals, dispute, 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 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.
• Apply contract language, benefits, and review of covered services.
• 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 relating to claims payment and requests for claim adjustments or to requests from outside agencies.

JOB QUALIFICATIONS REQUIRED EDUCATION: High School Diploma or equivalency

REQUIRED EXPERIENCE:

• Min. 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