Job Description
Job Summary

Researches and documents Medicaid and Medicare Advantage denial determinations for reconsiderations/appeals in a thorough, professional and expedient manner.  May include evaluation for medical necessity and appropriate levels of care.

  Knowledge/Skills/Abilities Reviews, classifies, researches, and resolves member complaints (grievances and/or appeals) and communicates resolution in writing to members and providers or their authorized representatives in accordance with standards and requirements established by the Centers for Medicare and Medicaid.  Educates providers, members and their family members of Medicare and Medicaid grievance and appeals rights. Determines member eligibility and utilization history using various Molina systems and databases (e.g., membership, claims, prior authorization, case management, and complaint tracking systems). Researches provider and member’s covered benefits under both Medicare and Medicaid, using member utilization and medical records obtained for the purpose of critically reviewing provider and member’s complaint. Coordinates with pertinent departments and treating providers to effectuate timely resolution resulting from grievance and appeals decisions made at the plan level or by independent review entities. Collects, analyzes, and interprets grievance and appeals data.  Develops tracking/trending reports at prescribed frequencies for the purpose of identifying and communicating root causes of member dissatisfaction. Recommends process improvements within the Molina Medicare organization to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum STAR ratings.   Job Qualifications

REQUIRED EDUCATION:

Associate's degree or equivalent experience

REQUIRED EXPERIENCE:

4 years’ experience of analytical skills in a managed care setting. Excel, query, query, access VI experience Ability to analyze data and summarize and present findings Experience in customer/ provider and member services or prior authorization within a Medicare or Medicaid environment, may substitute for one year of the minimum required experience.                                                                                                               

 

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.