Appeals/Denials Specialist II at Charleston

Job Description

Job SummaryManages submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members and related outside agencies as a part of the integrated Healthcare Services Team. Conducts pertinent research, evaluates, responds and completes appeals and other inquiries accurately, timely and in accordance with all established regulatory guidelines. Prepares appeal summaries and correspondence and documents information for tracking/trending data.

Essential Functions* Enters denials and requests for appeal into information system and prepares documentation for further review.
* Researches issues utilizing systems and clinical assessment skills, knowledge and approved "Decision Support Tools" in the decision making process regarding health care services and care provided to members.
* Assure timeliness and appropriateness of all Provider appeals according to state and federal and Molina Healthcare guidelines.
* Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research.
* Evaluates for medical necessity and appropriate levels of care and formulates conclusions per protocol.
* Collaborates with Medical Directors and other team members to determine appropriate responses.
* Obtains Medical Director approval for determination per Molina protocol.
* Work with Customer Service to resolve balance bill issues and other member complaints regarding providers.
* Prepare responses to provider grievances / appeals.
* Elevates appeals to the appropriate committee and/or manager per protocol.
* Prepares and assists in the preparation of the narratives, graphs, flowcharts, etc. to be utilized for presentations and audits.
* Coordinates workflow between departments and interface with internal and external resources.
* Receive and resolve provider inquiries related to claims.
* Act as a liaison between the providers and health plan as appropriate.
* Assist with interdepartmental issues to help coordinate problem solving in an efficient and timely manner.
* Identifies and refers cases appropriately for Health Management, Case Management, Quality Improvement and Health Education per established triggers. Documents referral according to Molina Healthcare process.
* Creates and/or maintains statistics and reporting.

Knowledge/Skills/Abilities* Comprehensive knowledge of health care customer service, regulatory requirements and Provider Dispute and/or Member Appeal process.
* Knowledge of CPT/HCPC and ICD9 coding, procedures and guidelines.
* Comprehensive clinical decision logic and analysis skills.
* Excellent vocabulary, grammar, spelling, punctuation, and composition skills proven through the development of written communication.
* Maintain regular attendance based on agreed-upon schedule
* Computer skills and experience with Microsoft Office Products.
* Excellent verbal and written communication skills
* Ability to abide by Molinas policies
* Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) and fraud and abuse prevention detection policies and procedures
* Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

Required Education:
Nursing Degree, RN.

Required Experience:
Two years Utilization Review experience and two years of Managed Care experience.
Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials

Required Licensure/Certification:
Active, unrestricted State Licensed Register Nurse in good standing. Preferred Education:
Associate in Arts or Bachelors degreePreferred Experience:
Project Management

To all current Molina employees if you are interested in applying for this position please apply throug the intranet job listing. Also, fill out an Employee Transfer Request Form (ETR) and attach it to your profile when applying online.

Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Requirements

 
Country: USA, State: South Carolina, City: Charleston, Company: Molina Healthcare Inc..