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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…
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Torrance, California, United States · On-site
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Irvine, California, United States · On-site
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California, United States · On-site
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Yuba City, California, United States · On-site
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San Diego, California, United States · On-site
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Cupertino, California, United States · On-site
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West Sacramento, California, United States · On-site
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Anaheim, California, United States · On-site
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Carlsbad, California, United States · On-site
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Brea, California, United States · Hybrid
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Templeton, California, United States · On-site
$30/hr–$45/hr
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Costa Mesa, California, United States · On-site
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Los Altos, California, United States · On-site
$25/hr–$26/hr
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Fresno, California, United States · On-site
Apple Retail is where the best of Apple comes together. We bring our expertise to help people do what they love, delivering an only-at-Apple experience. We believe inclusion is a shared responsibility and we work togethe…
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Cupertino, California, United States · On-site
$90k–$98k/yr
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Skills: Financial management, Customer service, Leadership, Budgeting, Market dynamics
Long Beach, California, United States • On-site
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Leads and manages a team responsible for processing member and provider appeals and grievances in compliance with CMS standards. Oversees business process audits, stakeholder communication, and the preparation of regulatory reports and correspondence.
Requires at least 7 years of managed care experience in claims or appeals environments and at least 1 year of leadership experience. Candidates must have extensive knowledge of medical claims, regulatory guidelines, and proficiency in Microsoft Office.
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 intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Molina Healthcare is a FORTUNE 500 company that is focused exclusively on government-sponsored health care programs for families and individuals who qualify for government sponsored health care. Molina Healthcare contracts with state governments and serves as a health plan providing a wide range of quality health care services to families and individuals. Molina Healthcare offers health plans in Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Virginia, Washington and Wisconsin. Molina also offers a Medicare product and has been selected in several states to participate in duals demonstration projects to manage the care for those eligible for both Medicaid and Medicare.
Offices: 200 Oceangate, Long Beach, California 90802, US
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