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Appeals Specialist

Location : Los Angeles, CA
Job Type : Contract
Reference Code : 15210
Hours : Full Time
Travel : No
Relocation : No
Job Category : Healthcare - RNs & Nurse Management

Job Description :

MedNational is seeking candidates with experience in eligibility/enrollment and benefits, as well as experience with Member and/or Provider Appeals and Grievances.

Position will start remote, however will transition to an onsite position once Molina offices reopen in 2021. Candidate must be located in LA/OC area to qualify for the position.

Essential Functions:
• Resolves and prepares written response to incoming member or provider appeals, grievances, complaints and/or disputes.
• Researches claims processing guidelines, provider contracts, fee schedules and system configurations to determine root cause of payment error.
• Identifies potential provider problems through a proactive approach in which data is mined and trended to identify and prevent provider problem areas.
• Uses a variety of references to research and prepare healthcare provider information for loading into the health plan system/database; enters provider demographics, contract affiliation, or other data as needed.
• Interfaces with other departments regarding questions about provider configuration or other relevant provider issues.
• Composes all correspondence and appeal information concisely and accurately, in accordance with regulatory requirements.
• Maintains tracking system of correspondence and outcomes; maintains well-organized, accurate and complete files for all appeals, grievances, complaints and/or disputes.
• Monitors each request to ensure all internal and regulatory timelines are met.


Required Qualifications :

Required Education:
High School diploma or GED equivalent


Required Experience:
2-3 years experience in a managed care setting; CPT and ICD-9 coding, data entry, and 10-Key experience.
2-3 years managed care experience; claims review and processing background including coordination of benefits, subrogation, and eligibility criteria.

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