Specialist, Appeals & Grievances
- Military veterans preferred
2025-07-31 Molina Healthcare (https://careers.molinahealthcare.com/)
Other
/yr
full-time
employee
Albany New York United States
JOB DESCRIPTION
Job Summary
Responsible for reviewing and resolving Provider No Surprises Act cases in accordance with the standards and requirements established by the Centers for Medicare and Medicaid
KNOWLEDGE/SKILLS/ABILITIES
Responsible for the comprehensive research and resolution of Provider No Surprises Act cases to ensure that internal and/or regulatory timelines are met.
Research claims appeals and grievances using support systems to determine Provider No Surprises Act 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 Healthcare guidelines.
Responsible for meeting production standards set by the department.
Apply contract language, benefits, and review of covered services
Responsible for contacting the member/provider through written and verbal communication.
Prepares Provider No Surprises Act correspondence and document findings. Include information on trends if requested.
Composes all correspondence and Provider No Surprises Act information concisely and accurately, in accordance with regulatory requirements.
JOB QUALIFICATIONS
REQUIRED EDUCATION:
High School Diploma or equivalency
REQUIRED EXPERIENCE:
Min. 2 years operational managed care experience (call center, appeals or claims environment).
Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.
Familiarity with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for Provider No Surprises Act cases
Strong verbal and written communication skills
PREFERRED EXPERIENCE:
No Surprise Act Provider Disputes knowledge/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.
Pay Range: $21.16 - $38.37 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
