Specialist, Appeals & Grievances

JOB DESCRIPTION Job Summary Provides 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 Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. • Researches claims appeals and grievances using support systems to determine appropriate appeals and grievance 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 to claims review process. • Contacts members/providers as needed via written and verbal communications. • Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). • Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. • Researches claims processing guid