Job Title: Healthcare Providers Specialist
Shift - 8 am to 4:30 PM EST M-F
Term: Contract
Pay Rate: 16.80/hr w2
Job Responsibilities:
Responsible for reviewing and resolving provider disputes and communicating resolution to provider in accordance with the standards and requirements established by the Centers for Medicare and Medicaid.
Job Responsibilities:
- Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina providers and related outside agencies to ensure that internal and/or regulatory timelines are met.
- Research claims appeals and grievances using support systems to determine appeal 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 Healthcare guidelines.
- Responsible for contacting the member/provider through written and verbal communication.
- Prepares appeal summaries, correspondence, and document findings. Include information on trends if requested.
- Composes all correspondence and appeal/dispute and or grievances information concisely and accurately, in accordance with regulatory requirements.
- Research claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
- Resolves and prepares written response to incoming provider reconsideration request is relating to claims payment and requests for claim adjustments or to requests from outside agencies
TOP SKILLS:
- Provider Appeals and Grievance on the insurance side of the business
- Claims review/processing/billing & coding experience
- Healthcare Insurance Customer Service experience