Molina Healthcare's Appeals & Grievances jobs are responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.
Enters denials and requests for appeal into information system and prepares documentation for further review.
Researches issues utilizing systems and other available resources.
Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines.
Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research.
Determines appropriate language for letters and prepare responses to appeals and grievances.
Elevates appropriate appeals to the Appeals Specialist.
Generates and mails denial letters.
Assists with interdepartmental issues to help coordinate problem solving in an efficient and timely manner.
Creates and/or maintains statistics and reporting.
Works with member services to resolve balance bill issues and other member complaints regarding providers. Job Qualifications
High School Diploma or GED with at least two years of college or equivalent experience.
1 - 3 yrs experience in the medical field including one year of customer service or provider service experience in a managed care setting.
Required License, Certification, Association
Associate in Arts Degree
Claims experience in a managed care setting (medical office or hospital claims experience may substitute).
Preferred License, Certification, Association
Completion of a healthcare related vocational program in Managed Care or some other health care aspect providing a certificate at completion (i.e., Certified Coder, billing, medical assistant).
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.