Specialist, Appeals & Grievances
Molina Healthcare · United States
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- Hybrid
- Full-time
- $72,000 / year
- United States
Job highlights
- Resolve member and provider complaints for Medicare/CMS.
- Research and resolve appeals, disputes, and grievances.
- Review medical records and claims data.
- Communicate resolutions verbally and in writing.
- Meet claims production and regulatory standards.
About the role
Job Summary
Provides support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).
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).
Internal Applicant Notice
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Company Benefits
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Key skills/competency
- Appeals and Grievances
- Claims Processing
- Managed Care
- Medicare
- Medicaid
- Customer Service
- Regulatory Guidelines
- Medical Records Review
- Communication Skills
- Time Management
Skills & topics
- Appeals Specialist
- Grievances Specialist
- Managed Care
- Claims Processing
- Medicare
- Medicaid
- Healthcare
- Customer Service
- Regulatory Compliance
- CMS
How to get hired
- Tailor your resume: Highlight managed care, appeals, claims processing, and customer service experience.
- Showcase regulatory knowledge: Emphasize familiarity with Medicare and Medicaid appeals guidelines.
- Demonstrate communication skills: Provide examples of effective verbal and written communication.
- Prepare for interview: Be ready to discuss problem-solving and time management abilities.
- Apply strategically: Follow internal application procedures if a current employee.
Technical preparation
Review Medicare/Medicaid appeal regulations.,Practice using claims processing software.,Understand coordination of benefits concepts.,Familiarize yourself with medical record review.
Behavioral questions
Describe handling difficult member complaints.,How do you manage competing deadlines?,Tell me about a complex claims issue resolved.,How do you ensure accuracy in your work?
Frequently asked questions
- What are the primary responsibilities of an Appeals and Grievances Specialist at Molina Healthcare?
- As an Appeals and Grievances Specialist at Molina Healthcare, your primary role involves researching and resolving member and provider complaints, disputes, grievances, and appeals. This includes reviewing medical records and claims data, ensuring compliance with CMS regulations, and communicating resolutions both verbally and in writing. You will also be responsible for meeting production standards and documenting findings accurately.
- What experience is required for the Appeals and Grievances Specialist role at Molina Healthcare?
- The role requires at least 2 years of managed care experience in a call center, appeals, or claims environment. You should also have health claims processing experience, including knowledge of coordination of benefits, subrogation, and eligibility criteria. Experience with Medicare and Medicaid claims denials and appeals, along with an understanding of regulatory guidelines, is essential. Customer service experience and proficiency in Microsoft Office are also required.
- How does Molina Healthcare ensure appeals and grievances are handled according to regulations?
- Molina Healthcare ensures compliance by having specialists research and resolve appeals in accordance with standards set by the Centers for Medicare and Medicaid Services (CMS). The process involves applying contract language, reviewing covered services, and adhering to state, federal, and Molina guidelines for timeliness and appropriateness of responses. Accurate documentation and clear communication are key to maintaining regulatory adherence.
- What kind of communication skills are important for an Appeals and Grievances Specialist at Molina Healthcare?
- Effective verbal and written communication skills are crucial for this role. You will need to communicate complex resolutions clearly and concisely to members and providers, as well as compose accurate and compliant correspondence. This includes summarizing findings and detailing any trends identified during the research process.
- Can a vocational program in healthcare qualify me for the Appeals and Grievances Specialist position?
- While not strictly required, completion of a healthcare-related vocational program (like certified coder, billing, or medical assistant) is considered a preferred qualification. Combined with the required experience, this can strengthen your application by demonstrating a foundational understanding of healthcare operations.