Lead Specialist, Appeals & Grievances

JOB DESCRIPTION Job Summary Provides lead level support for claims activities including reviewing and resolving member and 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 Services (CMS). Essential Job Duties Serves as team lead for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members, providers and related outside agencies. • Trains new employees and provides guidance to others with respect to complex appeals and grievances. • Researches and resolves escalated issues including state complaints and high visible complex cases. • In conjunction with claims leadership, assigns claims work to team. • Prepares appeal summaries and correspondence, and documents information for tracking/trending data. • Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits; researches claims appeals and grievances using support systems to determine appeals and grievances outcomes. • Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Molina guidelines. • Meets claims production standards set by the department. • Applies contract language, benefits, and review of covered services. • Cont