Lead Analyst, Appeals & Grievances

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.

Required

KNOWLEDGE, SKILLS & ABILITIES (Generally, the occupational knowledge and specific technical and professional skills and abilities required to perform the essential duties of this job)

• 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.
• Guides staff by providing technical knowledge and functions as a subject matter expert to staff.
• 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.
• Serves as a lead for incoming analysts by providing support.
• Serves as a liaison between staff and supervisor to provide performance feedback and oversight of daily activities/work schedules/HR issues.
• 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.
• Reviews quality of work during real time intervals to ensure cases are complete and handled appropriately.
• Trains new employees and provides guidance to others with respect to the more complex appeals and grievances.
• Prepares draft narratives, graphs, flowcharts, etc. for use in presentations and audits.

Job Qualifications

REQUIRED EDUCATION:

Associate's degree or equivalent experience

Required Experience

• Ability to analyze data and summarize and present findings
• 5 years of analytical skills and experience (query data, excel, and SharePoint)
• Experience with Medicaid and Medicare claims denials and appeals processing, and knowledge of NCQA guidelines for appeals and denials.
• Experience with process improvement initiatives

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.