What are the responsibilities and job description for the Lead Analyst, Appeals & Grievances position at Molina Healthcare?
JOB DESCRIPTION
Job Summary
Researches and documents Medicaid and Medicare Advantage denial determinations for all levels of reconsiderations/appeals in a thorough, professional and expedient manner. May include evaluation for medical necessity and appropriate levels of care.
KNOWLEDGE, SKILLS & ABILITIES (Generally, the occupational knowledge and specific technical and professional skills and abilities required to perform the essential duties of this job):
Serves as a lead for incoming analysts by providing support.
Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.
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.
Reviews quality of work during real time intervals to ensure cases are complete and handled appropriately.
Guides staff by providing technical knowledge and functions as a subject matter expert to staff.
Serves as a liaison between staff and supervisor to provide performance feedback and oversight of daily activities/work schedules/HR issues.
Prepares appeal summaries, correspondence, and documents information for tracking/trending data.
Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits.
Collects, analyzes, and interprets grievance and appeals data. Develops tracking/trending reports at prescribed frequencies for the purpose of identifying and communicating root causes of member dissatisfaction.
Recommends process improvements within the Molina Medicare organization to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum STAR ratings.
Job Qualifications:
REQUIRED EDUCATION:
Associate's degree or equivalent experience
REQUIRED EXPERIENCE:
5 years of analytical skills and experience (query data, excel, and SharePoint)
Experience with process improvement initiatives
Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.
Ability to analyze data and summarize and present findings
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.
Job Summary
Researches and documents Medicaid and Medicare Advantage denial determinations for all levels of reconsiderations/appeals in a thorough, professional and expedient manner. May include evaluation for medical necessity and appropriate levels of care.
KNOWLEDGE, SKILLS & ABILITIES (Generally, the occupational knowledge and specific technical and professional skills and abilities required to perform the essential duties of this job):
Serves as a lead for incoming analysts by providing support.
Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.
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.
Reviews quality of work during real time intervals to ensure cases are complete and handled appropriately.
Guides staff by providing technical knowledge and functions as a subject matter expert to staff.
Serves as a liaison between staff and supervisor to provide performance feedback and oversight of daily activities/work schedules/HR issues.
Prepares appeal summaries, correspondence, and documents information for tracking/trending data.
Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits.
Collects, analyzes, and interprets grievance and appeals data. Develops tracking/trending reports at prescribed frequencies for the purpose of identifying and communicating root causes of member dissatisfaction.
Recommends process improvements within the Molina Medicare organization to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum STAR ratings.
Job Qualifications:
REQUIRED EDUCATION:
Associate's degree or equivalent experience
REQUIRED EXPERIENCE:
5 years of analytical skills and experience (query data, excel, and SharePoint)
Experience with process improvement initiatives
Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.
Ability to analyze data and summarize and present findings
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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