Idaho Staffing
Specialist, Appeals & Grievances (Medicare Appeals/Disputes)
Idaho Staffing, Meridian, Idaho, us, 83680
Job Summary
Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. Must be able to work 8am-5pm PST hours and rotate weekends and holidays. Must have Medicare Appeals and IRE experience. Knowledge/Skills/Abilities: 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. Meet production standards set by the department. Apply contract language, benefits, and review of covered services. Contact 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 relating to claims payment and requests for claim adjustments or to requests from outside agencies. Job Qualifications: Required Education: High School Diploma or equivalency. Required Experience: Minimum 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 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 - $38.37 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. Must be able to work 8am-5pm PST hours and rotate weekends and holidays. Must have Medicare Appeals and IRE experience. Knowledge/Skills/Abilities: 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. Meet production standards set by the department. Apply contract language, benefits, and review of covered services. Contact 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 relating to claims payment and requests for claim adjustments or to requests from outside agencies. Job Qualifications: Required Education: High School Diploma or equivalency. Required Experience: Minimum 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 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 - $38.37 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.