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.
Conducts audits of the health plan's Member Appeals & Grievances operations for quality and accuracy, as prescribed by established internal appeals/grievance audit policies and procedures and based on a predetermined audit schedule.
Work to be audited includes, but is not limited to: verifying the accuracy of appeal data loading, timely processing, and disposition (e.g., using correct appeal/denial letter).
Organizes and coordinates organizational response to official audits conducted by the Centers for Medicare and Medicaid Services, including preparation and evaluation of all associated documents and training of staff via mock audits.
Collects audit data, analyzes/interprets results, and prepares written reports of findings to management, on both an aggregate and individual associate performance level.
Tracks and trends audit results at prescribed frequencies to identify and communicate patterns of non-compliance with established standards and requirements (e.g., with respect to timeliness and accurate categorization and processing of work).
Coordinates with management team or others on training and improvement opportunities based on audit results. Conducts training as appropriate.
In a back-up role as needed, assists in reviewing, classifying, researching and resolving member complaints (grievances and/or appeals), using various Molina systems and databases, and communicating resolution in writing to members in accordance with standards and requirements established by the Centers for Medicare and Medicaid. Coordinates with pertinent departments and treating providers as needed to effectuate timely resolution.Job Qualifications
Associate's Degree or equivalent combination of education and work experience.
4 years of related experience in a managed healthcare setting, with at least 1 year in an auditing role.
Experience in customer/member services or prior authorization within a Medicare or Medicaid environment may substitute for up to two years of the minimum required experience.
Required License, Certification, Association
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.