Associate Specialist, Appeals & Grievances (Provider Medicaid / Marketplace)

Job Summary

Provides entry level support for claims activities including reviewing and resolving member and 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 Services (CMS).

Essential Job Duties

• Enters denials and requests for appeals into information system and prepares documentation for further review.
• Researches claims issues utilizing systems and other available resources.
• Assures timeliness and appropriateness of appeals according to state, federal and Molina guidelines.
• Requests and obtains medical records, notes, and / or detailed bills as appropriate to assist with research.
• Determines appropriate language for letters and prepares responses to member appeals and grievances.
• Elevate appropriate appeals to the next level for review.
• Generates and mails denial letters.
• Provides support for interdepartmental issues to help coordinate problem-solving in an efficient and timely manner.
• Creates and / or maintains appeals and grievances related statistics and reporting.
• Collaborates with provider and member services to resolve balance bill issues and other member / provider complaints.

Required Qualifications

At least 1 year of experience in claims, and / or 1 year of customer / provider service experience in a health care setting, or equivalent combination of relevant education and experience. Customer service experience. Organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. Effective verbal and written communication skills. Microsoft Office suite / applicable software program(s) proficiency.

Preferred Qualifications

Customer / provider experience in a managed care organization (Medicaid, Medicare, Marketplace and / or other government-sponsored program), or medical office / hospital setting experience. Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant).

Pay Range : $21.16 - $34.88 / HOURLY