Responsible for data collection and analysis regarding specific Provider and/or Member Inquiries, Disputes and/or Appeals. Develops necessary policies and procedures and oversees quality assurance measures related to Provider Disputes and or Member Appeals. Participates in the provider hearing process as well as alleviating unnecessary hearings through research, and assists departmental staff in claim research projects and service initiatives.
Duties and Responsibilities
• Researches and documents denial determinations at all levels of provider reconsiderations/appeals in a thorough, professional and expedient manner.
• Coordinates workflow between departments and interface with internal and external resources. Formulates conclusions.
• Prepares and assists in the preparation of the narratives, graphs, flowcharts, etc. to be utilized for committee presentations and audits.
• Composes all correspondence in accordance with regulatory requirements, to reflect accurate appeal information in a clear, concise, grammatically correct format.
• Maintains tracking system of correspondence and outcomes for Provider and/or Member Denials and/or Appeals. Maintain well-organized, accurate and complete files for all appeals.
• Monitors each appeal to ensure all internal and regulatory timelines are met.
• Acts as point of contact for submission and/or resolution of denial determinations, practitioner appeals, and interfaces with Provider and/or Member Services in regards to Provider and/or Member reconsiderations, disputes and/or appeals.
• Assesses level of determination and/or appeal. Completes appropriate documentation for tracking/trending data.
• Conducts all pertinent research in order to evaluate, respond and close incoming written practitioner appeals and reconsiderations accurately, timely and in accordance with all established regulatory guidelines.
• Interfaces with internal departments and external resources and organizations.
• Prepares and assist with reports.
Knowledge, Skills and Abilities
• Computer literacy and proficiency in programs such as Microsoft Excel and Word
• Comprehensive understanding of state and regulatory grievance and confidentiality regulations
• Working knowledge of grievance hearing protocols
• Facilitation and CQI skills/training
• Professional writing and public speaking skills
• Attention to logic and detail; math and problem solving skills
• Ability to handle confidential material with culturally sensitive discretion and integrity
• Excellent interpersonal and 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) 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
• Other duties as assigned.
• High school graduate with two (2) years formal education in business or equivalent experience
• 5 years managed care experience.
• Managed Care concepts, claims processing background including coordination of benefits, subrogation, and eligibility criteria.
To all current Molina employees if you are interested in applying for this position please fill out an Employee Transfer Request Form (ETR) and attach it to your profile when applying online. Be sure to let us know you are a current employee by selecting “Molina Employee (current) in the source section of the online application.
Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
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