Associate Specialist, Appeals & Grievances

About This Role

This entry-level role provides support for claims activities, focusing on resolving member and provider complaints about appeals and grievances, ensuring compliance with CMS standards.

Responsibilities

• Enter denials and requests for appeals into the information system and prepare documentation for further review
• Research claims issues utilizing systems and other available resources
• Assure timeliness and appropriateness of appeals according to state, federal and Molina guidelines
• Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research
• Determine appropriate language for letters and prepare responses to member appeals and grievances
• Elevate appropriate appeals to the next level for review
• Generate and mail denial letters
• Provide support for interdepartmental issues to help coordinate problem-solving
• Create and/or maintain appeals and grievances related statistics and reporting
• Collaborate with provider and member services to resolve balance bill issues and other member/provider complaints

Requirements

• At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting
• Customer service experience
• Organizational and time management skills
• Effective verbal and written communication skills
• Microsoft Office suite/applicable software program(s) proficiency

Qualifications

• At least 1 year of experience in claims, and/or 1 year of customer/provider service experience in a health care setting, or equivalent combination of relevant education and experience.

Nice to Have

• Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting experience
• Completion of a health care related vocational program (i.e., certified coder, billing, or medical assistant)

Skills

* Required skills

Benefits