**JOB DESCRIPTION** **Job Summary** Responsible for reviewing and resolving member and provider complaints and communicating resolution to members and provider (or authorized representatives) in accordance with the standards and requirements established by Medicaid. **KNOWLEDGE/SKILLS/ABILITIES** + Responsible for the comprehensive research and resolution of the appeals, dispute, grievances, and/or complaints from Molina members, 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 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 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 **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 claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. + Strong verbal and written communication skills 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.