Job Summary
Responsible for leading, organizing and directing the activities of the Medicare Duals Grievance and Appeals Unit that is responsible for reviewing and resolving member and provider complaints, appeals, and claim disputes, and communicating resolution to members, providers, or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid. This position will provide direct support to the implementation efforts specific to Medicare Duals.
Knowledge/Skills/Abilities
• Position requires extensive knowledge in Medicare plans to include DSNP, HIDE, FIDE, EAE, AIP, etc.
• Provides direct oversight, monitoring and training of provider disputes and appeals to ensure adherence with Medicare standards and requirements related to member and provider dispute/appeals processing.
•Requires state level knowledge and experience of Integrated Dual plans apply state level requirements to meet contract and regulatory expectations.
• Establishes Appeals & Grievances department policies and procedures in line with federal and state regulations.
Establishes internal key performance metrics in line with state and federal regulations. Responsible for managing the Appeals and Grievance department inventories within the key performance requirements.
• Coordinates with Customer/Member services, Provider Services, Sales, Enrollment, UM, Case Management, Claims, and other departments within Molina Medicare and Medicaid regarding A&G operations and dependencies.
• Responsible for the A&G department service levels to include internal and external reporting requirements.
• Reviews and analyzes, collects data along with audit results on unit's performance; analyzes and interprets trends and prepares reports that identify root causes for Appeals, Grievances, and Provider Disputes. Recommends and implements process improvements to achieve member/provider satisfaction or operational effectiveness/efficiencies which contribute to Molina Medicare's maximum STAR ratings.
Job Qualifications
Required Education
Associate's Degree or 4 years of Medicare experience
Required Experience
• 7 years experience in healthcare claims review and/or member appeals and grievance processing/resolution, including 3 years in a manager role.
• Experience with Medicare Regulations, Medicare Duals, Appeals & Grievances, Provider Disputes (Par and Non-Par) and overall Medicare program knowledge.
• Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, high dollar complicated claims, COB and DRG/RCC pricing).
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.