Job description

JOB DESCRIPTION

Job Summary

Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member and provider complaints and communicating resolution to provider and members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

KNOWLEDGE/SKILLS/ABILITIES

Supervises staff responsible for the submission/resolution of member and provider inquiries or grievances. Ensures resolutions are compliant.

Assesses and audits business processes to determine those most effective and efficient at resolving member and provider problems.

Interfaces with corporate counterparts and member services and ensures standard processes are implemented.

Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits, and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.

Maintains call tracking system and database of correspondence and outcomes for provider and member appeals; monitors each appeal to ensure all internal and regulatory timelines are met.

JOB QUALIFICATIONS

REQU I RED ED U C A TI O N :
Bachelor's degree or equivalent experience

REQU I RED E X PE R I E N C E:
5 years experience in claims review and member and provider appeal resolution.

Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing).

Previous experience leading projects or lead experience

PHY S I C AL DEM A N D S :
W o rki n g en v i r o nm ent is g e n erally f a vo r a b le and li gh t i n g and t e m p erature are a d eq u at e . W o rk is g eneral l y p erf o r m ed in an o ff i ce e n v i r o n m ent in w h i c h t h ere is o n l y m i n i m al e x p o su r e to u np leasa n t a nd /o r ha z ar d o u s w o rki n g c o nd iti o n s. M u s t h a v e t h e a b ility t o s i t f o r l o n g p eri o d s. Rea s o n a b le acc om mo d a ti o n s m a y be m a d e to e n a b le in d i v i du als with d i sa b ilities t o p er f o r m t h e e ssential fu n cti o n .

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.

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