Medicare Appeals & Grievances Specialist (PST Hours)

Join to apply for the Medicare Appeals & Grievances Specialist (PST Hours) role at Molina Healthcare . This position is remote and will be working Pacific Standard hours. Highly Qualified Candidates Will Have The Following Experience Strong understanding of UM, Appeals, and Medicare knowledge Strong understanding of CMS regulations, Medicare MMP regulations and state specific requirements Impeccable attention to detail AOR/IRE understanding highly preferred Essential Job Duties Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines. Meets claims production standards set by the department. Applies contract language, benefits and review of covered services to claims review process. Contacts members/providers as needed via written and verbal communications. Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies. 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. Preferred 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). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $21.16 - $38.37 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Seniority level Entry level Employment type Full-time Job function Other Industries Hospitals and Health Care #J-18808-Ljbffr Molina Healthcare, Inc.