Appeals Specialist I

 Title: -Appeals Specialist I
Location: Remote, CA
Duration:  3+ Months
Client: Molina Healthcare 17716-1
 
Description:
 
Molina is seeking candidates with experience in eligibility/enrollment and benefits, as well as experience with Member and/or Provider Appeals and Grievances and Claims review or Claims Processing.
Both backgrounds is nice, but Claims experience over grievances is preferred.
 
Candidate may sit anywhere in US. Available to work PST time zone.
 
Manages submission, intervention and resolution of appeals, grievances, complaints and/or disputes from Molina members or providers and related outside agencies. Conducts pertinent research, evaluates, responds and completes appeals, grievances, complaints and/or disputes and other inquiries accurately, timely and in accordance with all established regulatory guidelines. Prepares appeal summaries and correspondence and documents information for tracking/trending data.
 
Essential Functions:
• Resolves and prepares written response to incoming member or provider appeals, grievances, complaints and/or disputes.
• Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
• Identifies potential provider problems through a proactive approach in which data is mined and trended to identify and prevent provider problem areas.
• Uses a variety of references to research and prepare healthcare provider information for loading into the health plan system/database; enters provider demographics, contract affiliation, or other data as needed.
• Interfaces with other departments regarding questions about provider configuration or other relevant provider issues.
• Composes all correspondence and appeal information concisely and accurately, in accordance with regulatory requirements.
• Maintains tracking system of correspondence and outcomes; maintains well-organized, accurate and complete files for all appeals, grievances, complaints and/or disputes.
• Monitors each request to ensure all internal and regulatory timelines are met.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate 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.
 
Knowledge/Skills/Abilities:
Comprehensive knowledge of health care customer service, regulatory requirements and Provider Dispute and/or Member Appeal process. Knowledge of CPT/HCPC and ICD9 coding, procedures and guidelines. Excellent vocabulary, grammar, spelling, punctuation, and composition skills proven through the development of written communication. Maintain regular attendance based on agreed-upon schedule Computer skills and experience with Microsoft Office Products. Excellent verbal and written communication skills Ability to abide by Molinas policies Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) and fraud and abuse prevention detection policies and procedures Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
 
Required Education:
High School diploma or GED equivalent
 
Required Experience:
2-3 years experience in a managed care setting; CPT and ICD-9 coding, data entry, and 10-Key experience.
2-3 years managed care experience; claims review and processing background including coordination of benefits, subrogation, and eligibility criteria.