Job Summary
A healthcare company is in need of a Remote Appeals and Grievances Specialist.
Core Responsibilities of this position include:
- Researching issues utilizing systems and clinical assessment skills, knowledge and approved “Decision Support Tools” in the decision making process regarding health care services and care provided to members
- Requesting and reviewing medical records, notes, and/or detailed bills as appropriate; evaluates for medical necessity and appropriate levels of care; formulates conclusions per protocol and collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines
- Preparing appeal summaries, correspondence and documents information for tracking/trending data; assists in the preparation of narratives, graphs, flowcharts, etc. for presentations and audits
Skills and Requirements Include:
- High School Diploma or GED
- Min. 1 year Claims experience and 1 year managed care experience
- Claims processing background, including coordination of benefits, subrogation, and SB1264
- Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials
- Excellent communication skills
