Specialist, Appeals & Grievances
工作简介提供支持包括审查和解决成员和供应商的投诉，并根据医疗保健服务中心 (CMS) 所设定的标准和要求向成员或授权代表传达解决方案。基本职务 · 促进 Molina 成员，供应商和相关外部机构对投诉，纠纷，抱怨和/或投诉进行全面研究和解决，以确保满足内部和/或监管时间表。• 研究使用支持系统来确定适当的投诉和投诉结果。• 根据需要，要求并审查医疗记录，备忘录和/或详细的账单；以确定应对方案和其他商业伙伴制定结论；确保各州，联邦和莫利纳指南的反应及时性和合适性。•符合部门设定的索赔生产标准。•将合同语言，福利和覆盖服务的审查应用到索赔审查过程中。•通过书面和口头通信联系成员/提供者。•编制上诉总结和信件，并相应地文件调查结果 （如需）• 简洁，准确和符合法规要求的编写所有通信，上诉/争端和/或抱怨信息。• 研究索赔处理指南，提供商合同，费用日程表和系统配置，以确定付款错误的根本原因。•解决并为接入供应商关于支付索赔，调整索赔的请求和/或外部机构的请求做出书面回复。需要资格 · 在电话中心，上诉和/或索赔环境中至少2年的管理护理经验，或者相等教育和相关经验组合。• 医疗保险申请处理经验，包括福利协调 (COB),代购和资格标准。• 在医疗补助和医疗保养护申请拒绝和上诉处理方面的经验以及对上诉和否决的监管指南的知识。• 客户服务经验。·强大的组织能力和时间管理技能；同时管理项目和任务以满足内部截止日期的能力。• 有效的口头和书面沟通技巧。• Microsoft Office 套件
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JOB DESCRIPTION Job SummaryProvides support 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
- Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met.
- • Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines.
- • Meets claims production standards set by the department.
- • Applies contract language, benefits and review of covered services to claims review process.
- • Contacts members/providers as needed via written and verbal communications.
- • Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested).
- • Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements.
- • Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.
- • Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies.
Required Qualifications
- At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience.
- • Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria.
- • Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.
• Customer service experience.
- Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
- • Effective 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