Healthcare - Appeals Specialist I

Job Title

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

Job Description

Review, investigate, and resolve provider appeals and grievances. Analyze medical, claims, authorization, and benefit information to support case determinations. Ensure compliance with CMS, state, federal, and organizational requirements Prepare and distribute written acknowledgments, resolution letters, and determination notices. Maintain complete and accurate case documentation within designated systems. Monitor cases to ensure adherence to required turnaround times and regulatory deadlines. Research and interpret benefit plans, policies, procedures, and contractual requirements. Identify and escalate trends, quality concerns, and potential process improvement opportunities.

Expected Schedule

M-F, Time 8:30 - 5 in their time zone, (start and stop times are flexible).

Day-to-Day Job Duties

Review, investigate, and resolve provider appeals and grievances. Analyze medical, claims, authorization, and benefit information to support case determinations. Ensure compliance with CMS, state, federal, and organizational requirements Prepare and distribute written acknowledgments, resolution letters, and determination notices. Maintain complete and accurate case documentation within designated systems. Monitor cases to ensure adherence to required turnaround times and regulatory deadlines. Research and interpret benefit plans, policies, procedures, and contractual requirements. Identify and escalate trends, quality concerns, and potential process improvement opportunities.

Top Skills Required

Health plan or managed care experience. Knowledge of Medicare and Medicaid products. Previous claims or appeals/grievance experience.

Additional IT Equipment Required

dual monitor, connecting cables & docking station

Potential for Extension

Yes

Job Summary

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 is 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