Job Summary

Responsible for reviewing and resolving member & 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.

Knowledge/Skills/Abilities:

• Enters denials and requests for appeal into information system and prepares documentation for further review.
• Research issues utilizing systems and other available resources.
• Assures timeliness and appropriateness of appeals according to state and federal and Molina Healthcare guidelines.
• Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research.
• Determines appropriate language for letters and prepare responses to appeals and grievances.
• Elevate appropriate appeals to the Appeals Specialist.
• Generates and mails denial letters.
• Assists with interdepartmental issues to help coordinate problem solving in an efficient and timely manner.
• Creates and/or maintains statistics and reporting.
• Works with provider & member services to resolve balance bill issues and other member/provider complaints.

Job Qualifications:

High School Diploma or equivalency

Required Experience:

1 year of Molina experience, health claims experience, or one year of customer service/provider service experience in a managed care or healthcare environment. Strong verbal and written communication skills.

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. Pay Range: $21.16 - $34.88 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.