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Supv, Appeals & Grievances (Iowa Residents ONLY)

Company: Molina Healthcare
Location: Iowa Falls
Posted on: May 25, 2023

Job Description:

JOB DESCRIPTIONJob SummaryThis position will be supporting our Iowa health plan.Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member and provider complaints and communicating resolution to provider and members or-- authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and MedicaidKNOWLEDGE/SKILLS/ABILITIES

  • Supervises staff responsible for the submission/resolution of member and provider inquiries or grievances.-- Ensures resolutions are compliant.
  • Assesses and audits business processes to determine those most effective and efficient at resolving member and provider problems.
  • Interfaces with corporate counterparts and member services and ensures standard processes are implemented.
  • 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.
  • Maintains call tracking system and database of correspondence and outcomes for provider and member appeals; monitors each appeal to ensure all internal and regulatory timelines are met. JOB QUALIFICATIONSREQUIRED EDUCATION: Bachelor's degree or equivalent experienceREQUIRED EXPERIENCE:
    • 5-- years experience in claims review and member and provider appeal resolution.
    • 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).
    • Previous experience leading projects or lead experience PHYSICAL DEMANDS:Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. --Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.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.#PJClaims#LI-BEMORE

Keywords: Molina Healthcare, Des Moines , Supv, Appeals & Grievances (Iowa Residents ONLY), Other , Iowa Falls, Iowa

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