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 Medicaid
• Serves as team lead for a small group of employees responsible for submission, intervention and resolution of appeals, grievances, and/or complaints from Molina members and related outside agencies.
• Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.
• Researches issues utilizing systems and clinical assessment skills, knowledge and approved “Decision Support Tools” in the decision making process regarding health care services and care provided to members.
• Requests and reviews medical records, notes, and/or detailed bills as appropriate; evaluates for medical necessity and appropriate levels of care; formulates conclusions per protocol and collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Molina Healthcare guidelines.
• Prepares appeal summaries, correspondence and documents information for tracking/trending data.
• Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits.
Completion of an accredited LVN or LPN training program.
• Min. 3 years utilization review experience and 2 years managed care experience.
• Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.
Required License, Certification, Association
Active, unrestricted State Licensed Vocational Nurse or Licensed Practical Nurse in good standing.
Associate's or Bachelor's Degree
Project management experience.
Preferred License, Certification, Association
State Licensed Registered Nurse
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.
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