Talent.com
Molina Healthcare
Specialist, Appeals & GrievancesMolina Healthcare • Long Beach, CA, United States
No longer accepting applications
Specialist, Appeals & Grievances

Specialist, Appeals & Grievances

Molina Healthcare • Long Beach, CA, United States
26 days ago
Job type
  • Full-time
Job description

Claims Support Specialist

Provides 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

  • Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met.
  • Researches claims appeals and grievances using support systems to determine appropriate appeals and grievance outcomes.
  • Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines.
  • Meets claims production standards set by the department.
  • Applies contract language, benefits and review of covered services to claims review process.
  • Contacts members/providers as needed via written and verbal communications.
  • Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested).
  • Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements.
  • Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.
  • Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies.

Required Qualifications

  • At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
  • Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria.
  • Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
  • Customer service experience.
  • Strong 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.
  • Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant).

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Create a job alert for this search

Specialist, Appeals & Grievances • Long Beach, CA, United States

Similar jobs

BENEFITS SPECIALIST 1203 (REVISED 01/12/24)

Government JobsLos Angeles, CA, United States
Full-time +1

Annual Salary: $63,704 to $93,145.The salary in the Department of Water and Power is $76,629 to $95,212.Candidates from the eligible list are normally appointed to vacancies in the lower pay grade ... Show more

 • Promoted

Grievance & Appeals Coordinator

Pyramid ConsultingLos Angeles, CA, United States
Temporary

Grievance & Appeals CoordinatorImmediate need for a Grievance & Appeals Coordinator.This is a 12 Month Contract opportunity with long-term potential and is US(Remote).Employee benefits incl... Show more

 • Promoted

SEAL Officer

US NavyAvalon, CA, US
Full-time +1

SEAL Officers lead small, elite teams in maritime special operations worldwide, conducting high risk missions from sea, air, and land in support of national objectives.They plan and execute sensiti... Show more

 • Promoted

Negotiations Specialist

TradeJobsWorkForce90024 Los Angeles, CA, US
Full-time

Negotiations Specialist Job Duties: Call providers, navigate call trees to get to the right people Negoti... Show more

 • Promoted

Grievance and Appeals Coordinator

A-Line Staffing SolutionsLos Angeles, CA, United States
Full-time

A-Line Staffing is now hiring a Grievance and Appeals Coordinator in Woodland Hills, CA.The Grievance and Appeals Coordinator would be working for a Fortune 500 company and has career growth potent... Show more

 • Promoted

Assoc Claims Specialist

Liberty Mutual InsuranceLos Angeles, CA, United States
Full-time

Schedule:Full-Time Salary Range:USD $50000.Job Category:Claims Description Under direct supervision, develops the knowledge and skills needed to conduct thorough investigations, make decisions abou... Show more

 • Promoted

Canvassing/ Campaigning

Depository SolutionLos Angeles, CA, United States
Part-time

OverviewJoin our dynamic team as a Canvassing and Campaigning Specialist, where your energy and communication skills will drive impactful outreach efforts! In this role, you will engage with commun... Show more

 • Promoted

Oceanographer/Meteorologist

US NavyAvalon, CA, US
Full-time

Oceanography (OCEANO) Officers, also called METOC, are the Navy's geophysical experts who understand and apply all facets of meteorology, oceanography, hydrography, bathymetry, geophysics, and prec... Show more

 • Promoted

Naval Flight Officer and Pilot

US NavyAvalon, CA, US
Full-time

Naval Aviation Officer (Pilot / Naval Flight Officer / AMDO).Naval Aviation Officers serve as Pilots, Naval Flight Officers, and Aviation Maintenance Duty Officers who operate and support one of th... Show more

 • Promoted

Specialist, Employee Relations

Los Angeles County Museum of Art (LACMA)Los Angeles, CA, United States
Full-time

Specialist, Employee Relations.Reporting to the Vice President of People & Culture, the Employee Relations Specialist plays a key role in fostering a positive and respectful work environment at LAC... Show more

 • Promoted

Career Opportunities: Proposal Specialist (12478)

SmithGroupLos Angeles, CA, United States
Full-time

SmithGroup is an integrated design firm with a reputation for cultivating a top-ranked culture while pioneering award-winning innovative design solutions.We blend research, data and technology with... Show more

 • Promoted

Remote Grievance & Appeals Coordinator

A-Line Staffing SolutionsLos Angeles, CA, United States
Remote
Full-time

A-Line Staffing is hiring a Full-Time, Remote, Grievance & Appeals Coordinator residing in or near the Woodland Hills, or Natomas, CA region! (MUST PASS A COMPUTERS BASIC TEST AND A TYPING TEST... Show more

 • Promoted

Client Account Arrangement Specialist

CooleySanta Monica, CA, United States
Full-time

Client Account Arrangement SpecialistCooley is seeking a Client Account Arrangement Specialist to join the Accounting team.Position summary:The Client Account Arrangement Specialist will provide su... Show more

 • Promoted

Subrogation Specialist

Argo GroupLos Angeles, CA, United States
Full-time

Argo Group is an underwriter of specialty insurance products in the property and casualty market.Argo offers a full line of products and services designed to meet the unique coverage and claims-han... Show more

 • Promoted

Proposal Specialist

Gannett Fleming, Inc.Los Angeles, CA, United States
Full-time

GFT is seeking a Proposal Specialist to join our BD&M team in the West (California/Phoenix/Seattle).This role follows a fully remote work model.Experience preparing proposals for capital public wor... Show more

 • Promoted

Senior Claims Specialist

Westfield InsuranceLos Angeles, CA, United States
Full-time

Claims ManagerDirectly handle, manage and/or oversee commercial and financial lines Public and Private D&O, Financial Institutions E&O, EPL, Fiduciary and Crime/Fidelity claims.Handle claim... Show more

 • Promoted

Surface Warfare Officer

US NavyAvalon, CA, US
Full-time

Surface Warfare Officers lead at sea by managing ship operations, combat systems, navigation, and warfare tactics to ensure mission readiness across the Fleet on destroyers, cruisers, amphibious sh... Show more

 • Promoted

Appeals and Grievances Lead - (LA18808)

3 Key ConsultingLos Angeles, CA, United States
Full-time

Key Consulting is recruiting an Appeals and Grievances Lead for a consulting engagement with our direct client, a leading government-funded managed care health plan.The Lead of Customer Solution Ce... Show more

 • Promoted

Senior Claims Specialist

WestfieldLos Angeles, CA, United States
Full-time

Commercial And Financial Lines Claims Manager.Wilshire Boulevard, Los Angeles, CA, 90036, US (Hybrid).Directly handle, manage and/or oversee commercial and financial lines public and private D&O, F... Show more

 • Promoted

Aviation Operations & Support

US NavyAvalon, CA, US
Full-time

Aviation Operations & Support (Enlisted).Aviation Boatswain’s Mates in Aviation Operations & Support help launch and recover naval aircraft quickly and safely from ships and shore stations, handlin... Show more