申诉与投诉成员-远程 EST
Manager, Appeals & Grievances Member- Remote EST
必须根据业务需求灵活前往SC办公室出差
职位描述 职位概述
负责管理处理索赔事务的团队，包括审查和解决会员和供应商的投诉，并根据医疗保险和医疗补助服务中心（CMS）制定的标准和要求，向会员或授权代表传达解决方案。
主要工作职责
- 管理负责提交/解决会员和供应商申诉及投诉的团队；确保解决方案符合相关标准和要求。
- • 评估和审计业务流程，以确定有效且高效的解决会员和供应商投诉的方法。
- • 作为与利益相关者和业务合作伙伴的主要接口，确保标准流程的实施。
- • 监督准备用于委员会汇报、审计和内部/外部报告的叙述性文字、图表、流程图等；根据监管要求监督必要的通信。
- • 确保满足部门设定的索赔生产标准。
- • 维护供应商和会员申诉/投诉的通信和结果的电话跟踪系统；监督/监控申诉，确保所有内部和监管时间限制得到遵守。
所需资格
- 至少7年在呼叫中心、申诉和/或索赔环境中的管理护理经验，或相关教育和经验的同等组合。
- • 至少1年管理/领导经验。
- • 具有审查各种类型医疗索赔的经验（如HCFA 1500、门诊/住院UB92、通用索赔、免赔额、手术、麻醉、高金额复杂索赔、COB和DRG/RCC定价）。
- • 具有医疗补助和医疗保险索赔拒绝和申诉处理经验，并了解申诉和拒绝的监管指南。
• 有领导项目的经验。
• 强烈的客户服务经验。
- 强大的组织和时间管理技能；能够同时管理多个项目和任务以满足内部截止日期。
- • 强大的口头和书面沟通能力。
- • 熟练使用Microsoft Office套件或相关软件程序。
优先资格
- 在管理护理组织（医疗补助、医疗保险、市场计划和其他政府资助计划）或医疗办公室/医院环境中具有客户/供应商经验。
- • 完成健康保险相关培训或认证。
查看英文原文
Must be flexable to travel to the SC office when needed due to buisnsess needs
JOB DESCRIPTION Job Summary
Leads and manages team responsible 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
- Manages team responsible for the submission/resolution of member and provider appeals and grievances; ensures resolutions are compliant with applicable standards and requirements.
- • Assesses and audits business processes to determine effective and efficient resolution of member and provider grievances.
- • Serves as primary interface with stakeholders and business partners, and ensures standard processes are implemented.
- • Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.
- • Ensures claims production standards set by the department are met.
- • Maintains call tracking system of correspondence and outcomes for provider and member appeals/grievances; oversees/monitors appeals to ensure all internal and regulatory timelines are met.
Required Qualifications
- At least 7 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
- • At least 1 year management/leadership experience.
- • Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high-dollar complicated claims, COB and DRG/RCC pricing).
- • Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Previous experience leading projects.
• Strong customer service experience.
- Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
- • Strong 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).
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Originally posted on Himalayas