Job Summary
Responsible for leading, organizing and directing the activities of the Medicare Contracted Provider Post-Pay Claim Appeals and Disputes 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 Medicare Contracted Provider Post-Pay Claim Appeals and Disputes that is responsible for reviewing and resolving contracted provider disputes for 20+ states.
• Provides direct oversight, monitoring and training of Contracted Provider disputes and appeals to ensure adherence with Molina claims processing standards and provider contractual agreements. Includes responsibility from start to finish of the claim disputes to include intake, processing, decisioning, adjusting, and responding timely to claim disputes. Team consists of clinical and non-clinical staff.
• Establishes Medicare Contracted Provider Post Pay dispute and appeals policies/procedures and updates annually or as directed otherwise.
• Collaborates with Health Plan leaders to ensure Contracted Provider appeals and disputes are processed in accordance with local Health Plan requirements
• Works with Claims, Configuration, Contracting, Provider Data Management, and other business partners to resolve provider concerns related to their claim’s dispositions.
• Provides robust root cause analysis identifying top drivers and works with Health Plans and other business partners to improve and reduce claim related appeals and disputes.
• Supports activities surrounding material updates including provider manuals, letters, and other correspondence related to Medicare Contracted Provider Appeals and Disputes.
• Responsible for meeting all departmental key performance indicators (KPI’s) with multiple targets depending on Medicare Program and State requirements.
Job Qualifications
Required Education
Associate's degree or 4 years of Medicare Claim Experience.
Required Experience
• 7 years' experience in healthcare claims review and/or Provider appeals and grievance processing/resolution, including 2 years in a manager role.
• Experience reviewing all types of medical claims (e.g. CMS 1500, Outpatient/Inpatient, Universal Claims, Surgery, Anesthesia, high dollar complicated claims, COB and DRG/RCC pricing), and IPA.
Preferred Education
Bachelor's degree
Previous Director experience.
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.