Specialist jobs at HCA Healthcare

- 50 jobs

CDI Reconciliation Specialist
HCA Healthcare 4.5
Specialist job at HCA Healthcare
****This is a fully remote role, but you must live within 60 miles of an HCA facility**** **Introduction** Do you want to join an organization that invests in you as a CDI Reconciliation Specialist? At HCA Healthcare, you come first. HCA Healthcare has committed up to $300 million in programs to support our incredible team members over the course of three years. **Benefits** HCA Healthcare offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include: + Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation. + Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. + Free counseling services and resources for emotional, physical and financial wellbeing + 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service) + Employee Stock Purchase Plan with 10% off HCA Healthcare stock + Family support through fertility and family building benefits with Progyny and adoption assistance. + Referral services for child, elder and pet care, home and auto repair, event planning and more + Consumer discounts through Abenity and Consumer Discounts + Retirement readiness, rollover assistance services and preferred banking partnerships + Education assistance (tuition, student loan, certification support, dependent scholarships) + Colleague recognition program + Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence) + Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Learn more about Employee Benefits (********************************************************************** **_Note: Eligibility for benefits may vary by location._** You contribute to our success. Every role has an impact on our patients' lives and you have the opportunity to make a difference. We are looking for a dedicated CDI Reconciliation Specialist like you to be a part of our team. **Job Summary and Qualifications** **Assessment of Documentation:** + Performs high priority retrospective reviews of the complete medical record and the coding summary of assigned population. + Analyzes documented and clinically supported conditions in multiple electronic health record technologies to ensure complete documentation. + Performs independent coding of the record to assure that the HIM coding accurately reflects the documentation. + Ensures documented conditions, clarifications, and coded diagnoses are clinically supported. + As appropriate, enters or revises Working and Target DRGs that accurately reflect expected CDI query impact. + Demonstrates knowledge of Official Coding Guidelines and the DRG Classification System to insure regulatory compliance related to the CDI and coding functions. + Identifies and documents education opportunities for CDI Specialists + Thoroughly documents reviews and other pertinent information in designated systems by established deadlines. + Achieves and maintains key operating metrics consistent with CDI Reconciliation program requirements. **HSC Escalation:** + Using critical thinking skills, independent discretion, clinical judgement, Official Coding Guidelines, DRG Classification, and Coding Clinics determines when and/or if escalation to the HSC is necessary. + Escalates DRG mismatches with coding opportunities as appropriate per established protocols. + Monitors and documents HSC responses. **Strategic Relationships:** + Develops and strengthens collaborative relationships with stakeholders to advance the care of our patients + Actively encourages collaboration and possesses excellent interpersonal skills in building and maintaining crucial relationships + Delivers information in a clear, concise and compelling manner to facilitate accomplishment of work goals + Delivers targeted and actionable communications that invites two-way professional communication. Adjusts messages appropriately by audience + Demonstrates a willingness and ability to assist others **Self-Development:** + Demonstrates proficiency in current and emerging technologies + Simultaneously uses multiple technologies to complete unique patient-level reviews + Independently takes proactive steps toward problem resolution + Completes all mandatory and assigned education by established deadlines + Attends scheduled meetings and continuing education programs **Education & Experience:** + Bachelor's degree required + 5+ years of experience in acute inpatient CDI or equivalent combination of education and/or experience required **Licenses, Certifications, & Training:** + Registered Nurse - Currently licensed as a Registered Professional Nurse in the state of residence + Or any coding credential nationally recognized as administered through AHIMA or ACDIS required + (CDIP) Certified Documentation Improvement Practitioner, or (RN) Registered Nurse, or (COC) Certified Outpatient Coder, or (CCS) Certified Coding Specialist, or (CPC) Certified Professional Coder, or (RHIA) Registered Health Information Administrator, or (RHIT) Registered Health Information Technician, or (ACDIS-CCDS) Certified Clinical Documentation Specialist HCA Healthcare (Corporate) (************************************************** , based in Nashville, Tennessee, supports a variety of corporate roles from business operations to administrative positions. Like our colleagues in any HCA Healthcare hospital, our corporate campus employees enjoy unparalleled **resources and opportunities** to reach their potential as healthcare leaders and innovators. From market rate compensation to continuing education and **career advancement opportunities** , every person has a solid foundation for success. Nashville is also home to our **Executive Development Program** , where exceptional employees are groomed to take on CNO- and COO-level roles in our hospitals. This selective program focuses on ethics, leadership and the financial and clinical knowledge required of professionals at this level of the industry. HCA Healthcare has been recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses. "Good people beget good people."- Dr. Thomas Frist, Sr. HCA Healthcare Co-Founder We are a family 270,000 dedicated professionals! Our Talent Acquisition team is reviewing applications for our CDI Reconciliation Specialist opening. Qualified candidates will be contacted for interviews. **Submit your resume today to join our community of caring!** We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
$45k-58k yearly est. 40d ago
Associate Specialist, Provider Contracts HP
Molina Healthcare Inc. 4.4
Columbus, OH jobs
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. Job Duties This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. * Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. * Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. * Forwards requested information/documentation to prospective providers in a timely manner. * Maintains database of all contracts and specific applications sent to prospective new providers. * Completes and updates Provider Information Forms for each new contract. * Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. * Sends out new provider welcome packets to providers who have contracted with the plan. * Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. * Formats and distributes Provider network resources (e.g. electronic specialist directory). Job Qualifications REQUIRED EDUCATION: High School Diploma or equivalent GED REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 1 year customer service, provider service, contracting or claims experience in the healthcare industry. PREFERRED EDUCATION: Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience PREFERRED EXPERIENCE: Managed Care 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. Pay Range: $21.16 - $42.2 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.2-42.2 hourly 6d ago
Associate Specialist, Provider Contracts HP
Molina Healthcare 4.4
Cleveland, OH jobs
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. **Job Duties** This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. - Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. - Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. - Forwards requested information/documentation to prospective providers in a timely manner. - Maintains database of all contracts and specific applications sent to prospective new providers. - Completes and updates Provider Information Forms for each new contract. - Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. - Sends out new provider welcome packets to providers who have contracted with the plan. - Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. - Formats and distributes Provider network resources (e.g. electronic specialist directory). **Job Qualifications** **REQUIRED EDUCATION** : High School Diploma or equivalent GED **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES** : 1 year customer service, provider service, contracting or claims experience in the healthcare industry. **PREFERRED EDUCATION** : Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience **PREFERRED EXPERIENCE** : Managed Care 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. Pay Range: $21.16 - $42.2 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$21.2-42.2 hourly 4d ago
Associate Specialist, Provider Contracts HP
Molina Healthcare Inc. 4.4
Cleveland, OH jobs
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. Job Duties This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. * Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. * Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. * Forwards requested information/documentation to prospective providers in a timely manner. * Maintains database of all contracts and specific applications sent to prospective new providers. * Completes and updates Provider Information Forms for each new contract. * Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. * Sends out new provider welcome packets to providers who have contracted with the plan. * Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. * Formats and distributes Provider network resources (e.g. electronic specialist directory). Job Qualifications REQUIRED EDUCATION: High School Diploma or equivalent GED REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 1 year customer service, provider service, contracting or claims experience in the healthcare industry. PREFERRED EDUCATION: Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience PREFERRED EXPERIENCE: Managed Care 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. Pay Range: $21.16 - $42.2 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.2-42.2 hourly 6d ago
Associate Specialist, Provider Contracts HP
Molina Healthcare Inc. 4.4
Akron, OH jobs
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. Job Duties This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. * Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. * Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. * Forwards requested information/documentation to prospective providers in a timely manner. * Maintains database of all contracts and specific applications sent to prospective new providers. * Completes and updates Provider Information Forms for each new contract. * Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. * Sends out new provider welcome packets to providers who have contracted with the plan. * Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. * Formats and distributes Provider network resources (e.g. electronic specialist directory). Job Qualifications REQUIRED EDUCATION: High School Diploma or equivalent GED REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 1 year customer service, provider service, contracting or claims experience in the healthcare industry. PREFERRED EDUCATION: Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience PREFERRED EXPERIENCE: Managed Care 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. Pay Range: $21.16 - $42.2 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.2-42.2 hourly 6d ago
Associate Specialist, Provider Contracts HP
Molina Healthcare Inc. 4.4
Cincinnati, OH jobs
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. Job Duties This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. * Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. * Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. * Forwards requested information/documentation to prospective providers in a timely manner. * Maintains database of all contracts and specific applications sent to prospective new providers. * Completes and updates Provider Information Forms for each new contract. * Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. * Sends out new provider welcome packets to providers who have contracted with the plan. * Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. * Formats and distributes Provider network resources (e.g. electronic specialist directory). Job Qualifications REQUIRED EDUCATION: High School Diploma or equivalent GED REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 1 year customer service, provider service, contracting or claims experience in the healthcare industry. PREFERRED EDUCATION: Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience PREFERRED EXPERIENCE: Managed Care 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. Pay Range: $21.16 - $42.2 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.2-42.2 hourly 6d ago
Associate Specialist, Provider Contracts HP
Molina Healthcare Inc. 4.4
Dayton, OH jobs
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. Job Duties This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. * Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. * Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. * Forwards requested information/documentation to prospective providers in a timely manner. * Maintains database of all contracts and specific applications sent to prospective new providers. * Completes and updates Provider Information Forms for each new contract. * Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. * Sends out new provider welcome packets to providers who have contracted with the plan. * Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. * Formats and distributes Provider network resources (e.g. electronic specialist directory). Job Qualifications REQUIRED EDUCATION: High School Diploma or equivalent GED REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 1 year customer service, provider service, contracting or claims experience in the healthcare industry. PREFERRED EDUCATION: Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience PREFERRED EXPERIENCE: Managed Care 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. Pay Range: $21.16 - $42.2 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.2-42.2 hourly 6d ago
Associate Specialist, Provider Contracts HP
Molina Healthcare 4.4
Ohio jobs
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. **Job Duties** This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. - Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. - Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. - Forwards requested information/documentation to prospective providers in a timely manner. - Maintains database of all contracts and specific applications sent to prospective new providers. - Completes and updates Provider Information Forms for each new contract. - Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. - Sends out new provider welcome packets to providers who have contracted with the plan. - Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. - Formats and distributes Provider network resources (e.g. electronic specialist directory). **Job Qualifications** **REQUIRED EDUCATION** : High School Diploma or equivalent GED **REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES** : 1 year customer service, provider service, contracting or claims experience in the healthcare industry. **PREFERRED EDUCATION** : Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience **PREFERRED EXPERIENCE** : Managed Care 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. Pay Range: $21.16 - $42.2 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
$21.2-42.2 hourly 4d ago
Associate Specialist, Provider Contracts HP
Molina Healthcare Inc. 4.4
Ohio jobs
Molina Health Plan Provider Network Contracting jobs are responsible for the network strategy and development with respect to adequacy, financial performance and operational performance, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations. Responsible for accurate and timely maintenance of critical provider information on all claims and provider databases. Synchronizes data among multiple claims systems when available, and the application of business rules as they apply to each database. Validate data to be housed on provider databases and ensure adherence to business and system requirements of customers as it pertains to contracting, network management and credentialing. Job Duties This role supports negotiations with assigned contracts and letters of agreements with non-complex provider community that result in high quality, cost effective and marketable providers. Maintains tracking system and publish reports according to departmental procedures. * Sends out contracts/applications to prospective providers upon request of Director or Manager and/or Provider Contracting and/or Provider Relations team members. * Receives calls from prospective providers and answers questions regarding contracting process, policies and procedures. * Forwards requested information/documentation to prospective providers in a timely manner. * Maintains database of all contracts and specific applications sent to prospective new providers. * Completes and updates Provider Information Forms for each new contract. * Ensures accuracy and completeness of provider demographic information and coordinates communication of such information to Provider Configuration team. * Sends out new provider welcome packets to providers who have contracted with the plan. * Utilizes Plan's system to track and follow up with Providers who have not responded to Contracts and/or Applications sent as directed by management. * Formats and distributes Provider network resources (e.g. electronic specialist directory). Job Qualifications REQUIRED EDUCATION: High School Diploma or equivalent GED REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: 1 year customer service, provider service, contracting or claims experience in the healthcare industry. PREFERRED EDUCATION: Associate's Degree or Bachelor's Degree in a related field or an equivalent combination of education and experience PREFERRED EXPERIENCE: Managed Care 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. Pay Range: $21.16 - $42.2 / HOURLY * Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. About Us Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
$21.2-42.2 hourly 6d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Columbus, OH jobs
Provides support for CA Medi-Cal and Marketplace benefits and services including reviewing and resolving member appeals and complaints, then communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the CA Department of Managed Health Care (DMHC) and CA Department of Health Care Services (DHCS) **Essential Job Duties** - Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. - Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits and review of covered services to claims review process. - Contacts members/providers as needed via written and verbal communications. - Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). - Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Effective verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 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.
$21.2-38.4 hourly 31d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Columbus, OH jobs
Provides support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. - Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits and review of covered services to claims review process. - Contacts members/providers as needed via written and verbal communications. - Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). - Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Effective verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 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.
$21.2-38.4 hourly 11d ago
Practice Transformation Specialist
Community Health Systems 4.5
Remote
This position will schedule virtual or (permitting) in-person visits to assigned provider practices. This position serves as a consultant to assist in the transition to value-based care by enhancing provider practice skills in process improvement and quality, sharing identified practice population trends, and analyzing data and performance measurements. The position will be hybrid/remote. Essential Duties and Responsibilities Support operations, promote development, and maintain industry knowledge related to: Accountable Care Organizations (ACOs) Clinically Integrated Networks (CINs) Other value-based care models as applicable Provide data support to providers by exporting data, running reports, and analyzing trends, and demonstrate proficiency in interpreting the key insights and improvement areas to communicate to practices. Provide general support of payer-driven and value-based quality programs. This includes but is not limited to Medicare Traditional and Advantage, Commercial, governmental, ACO, BPCI, CJR, and other quality-related and value-based reimbursement programs. Schedule monthly/quarterly visits to assigned group practices in order to assist the physicians and staff with practice transformation action plans and update on progress toward established goals. Support annual regulatory reporting submission requirements related to Medicare Quality programs (CQM, eCQM, MIPS, etc.) through coordination of data collection and submission. Assist as needed in EMR data extraction, chart reviews, and quality data collection for assigned practices. Develop deep practice understanding by listening to providers and staff to help identify areas for improvement. Understand practice-level challenges and barriers to achieving goals and share solutions for effectively resolving these issues. Partner with assigned practices to train clinicians and office staff on workflows to incorporate into their daily activities that drive toward outcomes in the practice that improve care and reduce costs. Collaborate on the development of training materials, project plans, tool kits, and evaluation materials. Deliver practice-level training and toolkits for improving member care. Review performance reports, quality dashboards and identify and develop suggestions for improvement plans for assigned practices. Willingness to travel in assigned regions as needed. Qualifications Required Education: Bachelor's Degree from accredited school/university. Preferred Education: Masters degree in relevant field preferred, relevant clinical/operational experience can be substituted. Local candidates are preferred but will consider Remote *** Up to 20% travel required*** Required Experience: 3-5 years of experience in practice engagement or operations, nursing, health technology, healthcare coding, population health, office management, or other healthcare related fields. Excellent verbal/written communication, interpersonal, and customer service skills. Moderate analytic knowledge needed to interpret and explain reports. Preferred Experience: Experience with Electronic Health Records (EHR) for clinical/practice management processes. Computer Skills Required: Proficient in Microsoft Office products such as Word, Excel, PowerPoint, email applications and in at least one analytics platform.
$25k-30k yearly est. Auto-Apply 11d ago
Cloud Specialist
Community Health Systems 4.5
Remote
Community Health Systems is seeking cloud specialist for The Cloud Center of Excellence (CCoE) which is building a scalable, secure, and cost-efficient multi-cloud foundation across Google Cloud Platform (GCP), Oracle Cloud Infrastructure (OCI), and Microsoft Azure. This role will play an integral part roles enable seamless collaboration across architecture, engineering, data, and security teams-driving modernization, cost optimization, and compliance through CCoE best practices. Key Responsibilities: Work collaboratively with architecture team in design, deployment, and governance of enterprise-scale cloud infrastructure. Implement automation frameworks, landing zones, and security controls. Champion FinOps initiatives to optimize spend and performance. Guide with CI/CD pipelines and infrastructure-as-code templates (Terraform, Ansible). Troubleshoot complex multi-cloud issues and guide operational excellence. Collaborate with architecture, security, and data teams to enforce compliance and resilience. Required Qualifications: Bachelor's or Master's in Computer Science, IT, or related discipline. 7-10 years in cloud engineering, DevOps, or platform architecture roles. Deep experience in GCP and OCI; exposure to Azure preferred. Proficiency in Terraform, Kubernetes, and CI/CD frameworks. Strong documentation, troubleshooting, and mentorship skills. Preferred certifications: Google Professional Cloud Architect OR OCI Architect Professional OR Azure Solutions Architect Expert. Soft Skills: Strong troubleshooting and analytical mindset Clear verbal and written communication Team player with ability to work independently and under pressure Strong documentation and customer-facing collaboration skills Why Join Us? Be part of a mission-driven organization serving over 65 hospitals and clinics Contribute to high-impact interoperability and modernization initiatives Work with next-generation platforms Grow within a high-performing integration and data engineering team
$25k-30k yearly est. Auto-Apply 37d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Akron, OH jobs
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 the Centers for Medicare and 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** **REQU** **I** **RED ED** **U** **C** **A** **TI** **O** **N** **:** High School Diploma or equivalency **REQU** **I** **RED E** **X** **PE** **R** **I** **E** **N** **C** **E:** + 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 and Medicare 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.
$21.2-38.4 hourly 7d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Cincinnati, OH jobs
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 the Centers for Medicare and 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** **REQU** **I** **RED ED** **U** **C** **A** **TI** **O** **N** **:** High School Diploma or equivalency **REQU** **I** **RED E** **X** **PE** **R** **I** **E** **N** **C** **E:** + 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 and Medicare 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.
$21.2-38.4 hourly 7d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Cincinnati, OH jobs
Provides support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. - Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits and review of covered services to claims review process. - Contacts members/providers as needed via written and verbal communications. - Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). - Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Effective verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 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.
$21.2-38.4 hourly 8d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Akron, OH jobs
Provides support for claims activities including reviewing and resolving member and provider complaints, and communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). **Essential Job Duties** - Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. - Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits and review of covered services to claims review process. - Contacts members/providers as needed via written and verbal communications. - Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). - Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Effective verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 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.
$21.2-38.4 hourly 11d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Cincinnati, OH jobs
Provides support for CA Medi-Cal and Marketplace benefits and services including reviewing and resolving member appeals and complaints, then communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the CA Department of Managed Health Care (DMHC) and CA Department of Health Care Services (DHCS) **Essential Job Duties** - Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. - Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits and review of covered services to claims review process. - Contacts members/providers as needed via written and verbal communications. - Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). - Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Effective verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 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.
$21.2-38.4 hourly 31d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Akron, OH jobs
Provides support for CA Medi-Cal and Marketplace benefits and services including reviewing and resolving member appeals and complaints, then communicating resolution to members or authorized representatives in accordance with the standards and requirements established by the CA Department of Managed Health Care (DMHC) and CA Department of Health Care Services (DHCS) **Essential Job Duties** - Facilitates comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Molina members, providers, and related outside agencies to ensure that internal and/or regulatory timelines are met. - Researches claims appeals and grievances using support systems to determine appropriate appeals 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 guidelines. - Meets claims production standards set by the department. - Applies contract language, benefits and review of covered services to claims review process. - Contacts members/providers as needed via written and verbal communications. - Prepares appeal summaries and correspondence, and documents findings accordingly (includes information on trends as requested). - Composes all correspondence, appeals/disputes and/or grievances information concisely, accurately and in accordance with regulatory requirements. - Researches claims processing guidelines, provider contracts, fee schedules and systems configurations, to determine root causes of payment errors. - Resolves and prepares written response to incoming provider reconsideration requests related to claims payment, requests for claim adjustments, and/or requests from outside agencies. **Required Qualifications** - At least 2 years of managed care experience in a call center, appeals, and/or claims environment, or equivalent combination of relevant education and experience. - Health claims processing experience, including coordination of benefits (COB), subrogation and eligibility criteria. - Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of regulatory guidelines for appeals and denials. - Customer service experience. - Strong organizational and time management skills; ability to manage simultaneous projects and tasks to meet internal deadlines. - Effective verbal and written communication skills. - Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** - Customer/provider experience in a managed care organization (Medicaid, Medicare, Marketplace and/or other government-sponsored program), or medical office/hospital setting. - Completion of a health care related vocational program in health care (i.e., certified coder, billing, or medical assistant). To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 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.
$21.2-38.4 hourly 31d ago
Specialist, Appeals & Grievances
Molina Healthcare 4.4
Dayton, OH jobs
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 the Centers for Medicare and 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** **REQU** **I** **RED ED** **U** **C** **A** **TI** **O** **N** **:** High School Diploma or equivalency **REQU** **I** **RED E** **X** **PE** **R** **I** **E** **N** **C** **E:** + 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 and Medicare 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.
$21.2-38.4 hourly 7d ago