Specialist, Appeals & Grievances

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 complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

Knowledge/Skills/Abilities

• Responsible for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members and related outside agencies.
• 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 for medical necessity and appropriate levels of care; formulates conclusions per protocol 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

Completion of an accredited LVN or LPN training program.

Required Experience

• 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

Associate's or Bachelor's Degree

Preferred Experience

N/A

Preferred License, Certification, Association

LVN/LPN or completion of other 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.