Leads and supervises 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

• Supervises team responsible for the submission/resolution of member and provider appeals and grievances, and 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.
• Interfaces with corporate counterparts and member services to ensure standards and processes are implemented in alignment with federal, state and Molina guidelines.
• 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 and database of correspondence and outcomes for provider and member appeals; monitors appeals to ensure all internal and regulatory timelines are met.
 

Required Qualifications

• At least 4 years of operational managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and 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 verbal and written communication skills.
• Strong customer service experience.  
• Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines.
• Microsoft Office suite proficiency.
 

Preferred Qualifications

• Management/leadership experience.
• 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.