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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.