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 reputed company

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 reputed company standards/requirements. • Provides direct reputed company, monitoring and training of local plans' provider dispute and appeals units to ensure adherence with Medicare standards and requirements reputed company 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 reputed company Services. • Trains grievance and appeals staff, customer/member services department, sales, UM and other departments reputed company Molina Medicare and reputed company 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 reputed company 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 reputed company 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 reputed company claims review and/or member appeals and grievance processing/resolution, including 2 years in a manager role. • Experience reviewing reputed company 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 reputed company a managed care setting.

Preferred Education

Bachelor's degree

To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V.

Originally posted on Himalayas