Responsible for all Provider Inquiry Resolution for the Plan. Under direct supervision, responsible for the submission/resolution of Provider Inquiries and Dispute Resolutions. Includes proactive assessment and audit of business processes to determine those most effective to efficiently and effectively resolve Provider Problems. Ensures documentation and reports are completed according to regulations. Serves as primary interface with Corporate counterparts and ensures standard processes are implemented. Maintains confidentiality as required.
• Oversees research and documentation for each Provider Inquiry and/or Dispute. Ensures resolution is compliant.
• Coordinates workflows between departments and interface with internal and external resources.
• Manages Provider Disputes database.
• Oversees preparation of the narratives, graphs, flowcharts, etc. to be utilized for committee presentations, audits, and any internal/external reports.
• Oversees necessary correspondence in accordance with regulatory requirements.
• Maintains call tracking system of correspondence and outcomes for Provider Disputes.
• Oversees monitoring of each Provider Dispute to ensure all internal and regulatory timelines are met.
• Maintains well-organized, accurate and complete files for all Provider Disputes.
• Complies with all Medicaid/Medicare requirements.
• Serves as liaison with Member Services in Plan.
• Knowledge of computerized claims processing systems
• Comprehensive knowledge of health care customer service, regulatory requirements and Provider Dispute process.
• Data entry and 10-key skills by touch and sight
• Knowledge of CPT/HCPC and ICD9 coding, procedures and guidelines
• Comprehensive medical terminology and knowledge
• Efficiency and accuracy of claim payments during processing and adjudication
• Excellent vocabulary, grammar, spelling, punctuation, and composition skills
• Ability to operate PC based software programs.
• Analytical ability
• Excellent verbal and written communication skills
• Ability to abide by Molina’s policies
• Ability to maintain attendance to support required quality and quantity of work
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members,
providers and customers
Associate’s Degree or 4+ years equivalent experience
• 4 years experience in claims review and Provider dispute resolution.
• Experience in reviewing all types of medical claims, e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, and Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing.
4+ years Provider dispute resolution experience.
Certified CPT Coder
Navigating the murky waters of federal health care plans is no easy feat, but Molina Healthcare's mission is to help Medicaid and...