Member Appeals & Grievances Specialist – Remote EST Position Available In Onondaga, New York

Job Order Number:

DG0209984

Job Title:

Member Appeals & Grievances Specialist – Remote EST

Company:

Molina Healthcare Location:

Syracuse, NY

Salary:

Education:

Information Not Provided

Experience:

Information Not Provided

Hours:

Duration:

Full Time, Regular

Shift:

Description:

 Molina Healthcare is hiring for an Appeals & Grievance Specialist. This role is remote and will be working an Eastern Time Zone schedule.

The Appeals & Grievance Specialist will be responsible for reviewing and resolving member disputes/complaints 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

• + 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

• 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 skillsTo 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 – $38.37 / HOURLY

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