Associate Specialist, Appeals & Grievances

JOB DESCRIPTION

Job Summary

Responsible for reviewing and resolving member & 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.

 

KNOWLEDGE/SKILLS/ABILITIES

• Enters denials and requests for appeal into information system and prepares documentation for further review.
• Research issues utilizing systems and other available resources.
• Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines.
• Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research.
• Determines appropriate language for letters and prepare responses to appeals and grievances.
• Elevates appropriate appeals to the Appeals Specialist.
• Generates and mails denial letters.
• Assists with interdepartmental issues to help coordinate problem solving in an efficient and timely manner.
• Creates and/or maintains statistics and reporting.
• Works with provider & member services to resolve balance bill issues and other member/provider complaints. 

 

JOB QUALIFICATIONS

REQUIRED EDUCATION:

High School Diploma or equivalency

REQUIRED EXPERIENCE:

• 1 year of Molina experience, health claims experience, OR one year of customer service/provider service experience in a managed care or healthcare environment.
• 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.