Director, Appeals & Grievances - REMOTE

Job Description

Job Summary Responsible for leading, organizing and directing the activities of the Grievance and Appeals Unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid

Knowledge/Skills/Abilities • Leads, organizes, and directs the activities of the Appeals & Grievances unit that is responsible for reviewing and resolving member complaints and communicating resolution to members or authorized representatives in accordance with Centers for Medicare and Medicaid standards/requirements. • Provides direct oversight, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements related to non-contracted provider dispute/appeals processing. • Establishes member and non-contracted provider grievance/dispute and appeals policies/procedures and updates annually or as directed by the Centers for Medicare and Medicaid Services. • Trains grievance and appeals staff, customer/member services department, sales, UM and other departments within Molina Medicare and Medicaid on early recognition and timely routing of member complaints. • Trains each state's provider dispute resolution unit on CMS standards and requirements, including the proper use of the Molina Provider Grievance and appeals system. • Reviews and analyzes collective grievance and appeals data along with audit results on unit's performance; analyzes and interprets trends and prepares reports that identify root causes of member dissatisfaction; recommends and implements process improvements to achieve member/provider satisfaction or operational effectiveness/efficiencies which contribute to Molina Medicare's maximum STAR ratings.

Job Qualifications Required Education Associate's degree or 4 years of Medicare grievance and appeals experience.

Required Experience • 7 years' experience in healthcare claims review and/or member appeals and grievance processing/resolution, including 2 years in a manager role. • Experience reviewing all types of medical claims (e.g. HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing). 2 years supervisory/management experience with appeals/grievance processing within a managed care setting.

Preferred Education

Bachelor's degree

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.

Originally posted on Himalayas