Associate Specialist, Appeals & Grievances

JOB DESCRIPTION Job Summary
Provides entry level 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**

• Enters denials and requests for appeals into information system and prepares documentation for further review.
• Researches claims issues utilizing systems and other available resources.
• Assures timeliness and appropriateness of appeals according to state, federal and Molina guidelines.
• Requests and obtains medical records, notes, and/or detailed bills as appropriate to assist with research.
• Determines appropriate language for letters and prepares responses to member appeals and grievances.
• Elevates appropriate appeals to the next level for review.
• Generates and mails denial letters....