Manager, Appeals & Grievances Member - Remote
Required skills
- managed care
- call center
- appeals
- claims
- medical claims
- HCFA 1500
- UB92
- Universal Claims
- Stop Loss
- Surgery
Nice to have
- managed care organization
- government-sponsored program
- medical office
- hospital setting
- billing
- medical assistant
Role summary
Leads and manages a team responsible for claims activities, including reviewing and resolving member and provider complaints, and communicating resolutions in accordance with CMS standards. Assesses business processes for efficient grievance resolution, serves as a primary interface with stakeholders, and oversees the preparation of reports and correspondence. Ensures claims production standards and regulatory timelines are met.
Member Focus
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
