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Company: Molina Healthcare
Location: Long Beach, CA
Career Level: Mid-Senior Level
Industries: Healthcare, Pharmaceutical, Biotech


Provider Inquiry Research & Resolution Manager

Molina Healthcare is seeking a Manager with claims, appeals, and dispute resolutions experience. Are you a leader? Are you ready for your next challenge? If so, then read on!

Together we are a driven, well-trained, positive-minded workforce able to provide quality health care to those who need it most. At Molina, we are committed to our vision: “We envision a future where everyone receives quality health care.”

Job Description Job Summary:
Molina Health Plan Operations jobs are responsible for the development and administration of our State health plan's operational departments, programs and services, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations.

Provider Inquiry/Services staff are responsible for the submission, research, and resolution of provider inquiries and/or disputes. They respond with the answer to all incoming inquiries and coordinate with other Molina departments as needed to resolve the issue, as well as to correct the underlying cause, ensuring that resolutions are timely and in compliance with all regulatory requirements.

Responsible for all day to day activities resulting in the resolution of provider appeals across all lines of business. Includes proactive assessment and audit of business processes to determine those most effective to efficiently and effectively resolve Provider appeals. Ensures documentation and reports are completed according to regulations. Serves as primary interface with Medical Directors, Health Services, Provider Inquiry Research and Resolution and plan leadership. Maintains and ensures integrity of files; prepares data reports and analysis of appeals.
• Manages staff responsible for the submission, research, and resolution of provider inquiries and/or disputes for the Plan. Ensures resolutions are compliant.
• Manages Provider Appeals through each stage of appeal to resolution, including adhering to all turn around times.
• Provides oversight of appeal policies and procedures specific to benefits, contracts and State requirements.
• Proactively assesses and audits business processes to determine those most effective and efficient at resolving provider problems.
• Serves as primary interface with Corporate Claims and Configuration counterparts and ensures standard processes are implemented.
• Oversees preparation of narratives, graphs, flowcharts, etc. to be used for committee presentations, audits and internal/external reports; oversees necessary correspondence in accordance with regulatory requirements.
• Maintains call tracking system and database of correspondence and outcomes for provider inquiries/disputes; oversees monitoring of each provider submission/resolution to ensure all internal and regulatory timelines are met.


Job Qualifications Required Education
Associates Degree or 6+ years equivalent work experience.
Required Experience
• Min. 4 years experience in healthcare claims review and/or provider dispute resolution.
• Knowledge of InterQual standards
• Knowledge of CPT/HCPC/DRG and ICD10 coding, procedures and guidelines
• Comprehensive knowledge of health care customer service, regulatory requirements and Provider Appeal process
• Comprehensive knowledge of medical terminology
Preferred Education
Bachelor's Degree in Healthcare or related field
Preferred Experience
• 6+ years experience in healthcare supervisory or management experience.
• 2+ years experience in management/supervisory role.

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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