Lead Specialist, Appeals & Grievances Position Available In New York, New York

JOB DESCRIPTION

Job Summary Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member grievances, regulatory complaints, Medicaid Fair Hearings and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.

KNOWLEDGE/SKILLS/ABILITIES

Serves as team lead for a small group of employees responsible for submission, intervention and resolution of grievances, and/or complaints from Molina members and related outside agencies. Review and evaluate appeal and grievance request to identify and classify member grievances, hand-off to appropriate department for appeals; regulatory complaints as appropriate to meet contractual obligations. Research and resolves escalated issues including state and regulatory complaints and high visible, complex cases. Where necessary, conduct thorough investigations of all member grievances by analyzing all the issues involved and obtaining responses and information from internal and external entities. Provide written acknowledgement of member correspondence, prepare written responses to all member correspondence that appropriately address each complaint issue and are structurally accurate. Perform inventory management and ensure that work is distributed appropriately to meet defined production standards and turn-around times. Identify and coordinate new hire and team member training needs based on performance, as well as team trends that may require implementing process improvements. Monitor and review case management dashboards and error reports to ensure productivity and case accuracy and timeliness. Maintain expertise in regulatory requirements and internal policies, ensuring compliance in all processes. Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, policies and procedures, and performance issues.

JOB QUALIFICATIONS REQUIRED EDUCATION

High School Diploma or equivalency

REQUIRED EXPERIENCE

3 years appeal and grievance experience Min. 3 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 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.

Pay Range:

$21.16 – $46.42 / HOURLY •Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.