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 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

KNOWLEDGE/SKILLS/ABILITIES

Serves as team lead for a small group of employees responsible for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies.
Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.
Research and resolves escalated issues including state complaints and high visible, complex cases.
Assign work to team.
Prepares appeal summaries, correspondence, and documents information for tracking/trending data.
Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits. Researches claims appeals and grievances using support systems to determine appeal 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 Healthcare guidelines.
Responsible for meeting production standards set by the department.
Apply contract language, benefits, and review of covered services
Responsible for contacting the member/provider through written and verbal communication.
Prepares appeal summaries, correspondence, and document findings.
Include information on trends if requested.
Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error (provider).
Resolves and prepares written response to incoming provider reconsideration requests relating to claims payment and requests for claim adjustments or to requests from outside agencies (Providers)

Please refer the Job description for details