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JOB DESCRIPTION

Provides support for claims activities including reviewing and resolving **Provider No Surprises Act** cases in accordance with the standards and requirements of Centers for Medicare and Medicaid Services (CMS).

Essential Job Duties

• Responsible for the comprehensive research and resolution of **Provider No Surprises Act** cases to ensure that internal and/or regulatory timelines are measured correctly.

• Researches claims using support systems to determine **Provider No Surprise Act** cases outcomes. .

• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response.

• Meets claims production standards set by the department.

• Applies contract language, benefits and review of covered services to claims review process.

• Contacts providers as needed via written and verbal communications.

• Prepares **Provider No Surprise Act** correspondence, and documents findings accordingly (includes information on trends as requested).

• Composes all correspondence, and **Provider No Surprise Act** information concisely and accurately in accordance with regulatory requirements.

• Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors.

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.

Pay Range: $21.16 - $38.37 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.