Specialist, Appeals & Grievances

Job Summary

Provides support for CA Medi-Cal and Marketplace benefits and services including reviewing and resolving member appeals and complaints, then communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the CA Department of Managed Health Care (DMHC) and CA Department of Health Care Services (DHCS)

Essential Job Duties

Facilitates comprehensive research and resolution of appeals, disputes, grievances, and / or complaints from Molina members, providers, and related outside agencies to ensure that internal and / or regulatory timelines are met. Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines. Meets claims production standards set by the department. Applies contract language, benefits and review of covered services to claims review process. Contacts members / providers as needed via written and verbal communications. Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). Composes all correspondence, appeals / disputes and / or grievances information concisely, accurately and in accordance with regulatory requirements. Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and / or requests from outside agencies.

Required Qualifications

At least 2 years of managed care experience in a call center, appeals, and / or claims environment, or equivalent combination of relevant education and experience. Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. Customer service experience. Strong 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. Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).