Job Description

Job Description

Job Summary
Responsible for leading, organizing, and directing the activities of the Grievance and Appeals Unit, which is responsible for reviewing and resolving member complaints, grievances and appeals. Team communicates the resolution of cases to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. Team works to identify and improve areas of concern within the health plan in order to improve members overall experience.

Knowledge/Skills/Abilities
Possesses strong written and verbal communication skills

* Demonstrates proactive problem-solving skills and is self-motivated
* Demonstrates strong computer skills and has ability to work within multiple programs as once
* Responsible for the research and resolution of regulatory complaints, state fair hearings, and second level appeals for Medicaid and Marketplace Molina members.
* Responsible for training new hires with support from department leadership.
* Responsible for the development and maintenance of department resource documents such as training guides, standard operating procedures and process flows.
* Researches issues utilizing systems and clinical assessment skills, knowledge and approved Decision Support Tools in the decision-making process regarding health care services and care provided to members.
* Requests and reviews medical records, notes, and/or detailed bills as appropriate; evaluates information to ensure that appropriate decision making occurred; formulates conclusions per protocols and guidelines; and collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines.
* Prepares appeal summaries, correspondence and documents information for tracking/trending data; assists in the preparation of narratives, graphs, flowcharts, etc. for presentations and audits.

Job Qualifications

Required Education
Associate's Degree
Required Experience
Min. 3 years experience in customer service

Min. 1 year utilization review experience and 1 year managed care experience.
Claims processing background, including coordination of benefits, subrogation, and eligibility criteria.
Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.
Preferred Education
Bachelor's Degree
Preferred Experience
N/A
Preferred License, Certification, Association
Completion of healthcare related vocational program with certification (e.g., Certified Coder, billing, medical assistant).

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.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full Time Posting Date: 03/18/2021