Specialist, Appeals & Grievances

Job Description

Provides support for claims activities including reviewing and resolving Provider No Surprises Act cases in accordance with the standards and requirements of Centers for Medicare and Medicaid Services (CMS). Essential Job Duties :

• Responsible for the comprehensive research and resolution of Provider No Surprises Act cases to ensure that internal and / or regulatory timelines are measured correctly.
• Researches claims using support systems to determine Provider No Surprise Act cases outcomes.
• Requests and reviews medical records, notes, and / or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response.
• Meets claims production standards set by the department.
• Applies contract language, benefits and review of covered services to claims review process.
• Contacts providers as needed via written and verbal communications.
• Prepares Provider No Surprise Act correspondence, and documents findings accordingly (includes information on trends as requested).
• Composes all correspondence, and Provider No Surprise Act information concisely and accurately in accordance with regulatory requirements.
• Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.

Required Qualifications :

Preferred Qualifications :

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 : $21.16 - $38.37 / HOURLY