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    Specialist-Contract - Albuquerque, NM, United States - Molina Healthcare

    Molina Healthcare
    Molina Healthcare Albuquerque, NM, United States

    2 weeks ago

    Default job background
    Description
    Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

    Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina members, providers and related outside agencies to ensure that internal and/or regulatory timelines are met.

    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; Apply contract language, benefits, and review of covered services
    Prepares appeal summaries, correspondence, and document findings. Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
    Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
    Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies

    2 years operational managed care experience (call center, appeals or claims environment).
    Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.

    Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials.

    97 / HOURLY
    *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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