Job Description
**JOB DESCRIPTION**
**Job Summary**
Responsible for reviewing and resolving member & 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**
+ Enters denials and requests for appeal into information system and prepares documentation for further review.
+ Research issues utilizing systems and other available resources.
+ Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines.
+ Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research.
+ Determines appropriate language for letters and prepare responses to appeals and grievances.
+ Elevates appropriate appeals to the Appeals Specialist.
+ Generates and mails denial letters.
+ Assists with interdepartmental issues to help coordinate problem solving in an efficient and timely manner.
+ Creates and/or maintains statistics and reporting.
+ Works with provider & member services to resolve balance bill issues and other member/provider complaints.
**JOB QUALIFICATIONS**
**REQU** **I** **RED ED** **U** **C** **A** **TI** **O** **N** **:**
High School Diploma or equivalency
**REQU** **I** **RED E** **X** **PE** **R** **I** **E** **N** **C** **E:**
+ 1 year of Molina experience, health claims experience, OR one year of customer service/provider service experience in a managed care or healthcare environment.
+ Strong verbal and written communication skills.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $21.16 - $34.88 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Job Tags
Hourly pay, Work experience placement,
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