Healthcare - Appeals Specialist I

Member Complaint Resolution Specialist Candidates must live in one of the preferred 15 states (AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI) and will be able to work in their own timezone schedule will be Monday to Friday8AM to 4:30PM. Job duties include: • Research member complaints • Update system to reflect research completed • Resolve member complaint within the timeframe Will require laptop, monitor, keyboard/mouse, headset. 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. Knowledge/Skills/Abilities: • Comprehensive research and resolution of appeals, dispute, grievances, and/or complaints from Molina members, providers and related outside agencies • Research claims appeals and grievances using support systems to determine outcomes • Requests and reviews medical records, notes, and/or detailed bills as appropriate • Formulates conclusions per protocol and other business partners to determine response • 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 • Composes all correspondence and appeal/dispute and/or grievances information concisely and accurately • 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: • Min. 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