Molina Healthcare
Associate Specialist, Appeals & Grievances
Molina Healthcare, Florida, New York, United States
Job Summary
Provides entry level support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).
Essential Job Duties
Enter denials and requests for appeals into the information system and prepare documentation for further review.
Research claims issues utilizing systems and other available resources.
Assure timeliness and appropriateness of appeals according to state, federal, and Molina guidelines.
Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research.
Determine appropriate language for letters and prepare responses to member appeals and grievances.
Elevate appropriate appeals to the next level for review.
Generate and mail denial letters.
Provide support for interdepartmental issues to help coordinate problem‑solving in an efficient and timely manner.
Create and/or maintain appeals and grievances related statistics and reporting.
Collaborate with provider and member services to resolve balance bill issues and other member/provider complaints.
Required Qualifications
At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting, or equivalent combination of relevant education and experience.
Customer service experience.
Organizational and time‑management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
Effective verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government‑sponsored program), or medical office/hospital setting experience.
Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant).
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $14.9 - $29.06 / HOURLY
Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Seniority level
Entry level
Employment type
Full-time
Job function
Other
Hospitals and Health Care
#J-18808-Ljbffr
Essential Job Duties
Enter denials and requests for appeals into the information system and prepare documentation for further review.
Research claims issues utilizing systems and other available resources.
Assure timeliness and appropriateness of appeals according to state, federal, and Molina guidelines.
Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research.
Determine appropriate language for letters and prepare responses to member appeals and grievances.
Elevate appropriate appeals to the next level for review.
Generate and mail denial letters.
Provide support for interdepartmental issues to help coordinate problem‑solving in an efficient and timely manner.
Create and/or maintain appeals and grievances related statistics and reporting.
Collaborate with provider and member services to resolve balance bill issues and other member/provider complaints.
Required Qualifications
At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting, or equivalent combination of relevant education and experience.
Customer service experience.
Organizational and time‑management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
Effective verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government‑sponsored program), or medical office/hospital setting experience.
Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant).
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $14.9 - $29.06 / HOURLY
Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Seniority level
Entry level
Employment type
Full-time
Job function
Other
Hospitals and Health Care
#J-18808-Ljbffr