This is a Full Remote job, available from anywhere.
The position will be 100% remote, with no specific location requirements, but a preference for the Eastern Time Zone.
The must-have requirements include:
- Experience working in A&G
- Ability to prioritize and work in a fast-paced environment
- Ability to work independently and as part of a team
The day-to-day responsibilities include:
- Entering appeals into a tracking system within contractual time limits
- Completing Acknowledgement letters
- Triage appeal cases and classify appeal type
The job requires a laptop, two monitors, docking station, keyboard/mouse, and headset.
Job Summary:
Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and providers in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.
Knowledge/Skills/Abilities:
- Comprehensive research and resolution of appeals, disputes, grievances, and complaints from Molina members, providers, and related outside agencies.
- Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
- Requests and reviews medical records, notes, and/or detailed bills as appropriate.
- Formulates conclusions per protocol and other business partners to determine response.
- Assures timeliness and appropriateness of responses per state, federal, and Molina Healthcare guidelines.
- Meets production standards set by the department.
- Applies contract language, benefits, and review of covered services.
