Job Description
Job Summary
Provides support through the investigation and resolution of disputes related to provider appeals, ensuring that claims adhere to correct billing standards and regulations.
Job Duties
- Reviews coding-related provider claims denials by systematically examining medical records, denial reasons, submitted claims, and claim history, in accordance with applicable state, federal, and Molina guidelines, rules, and protocols, to determine whether the documentation substantiates the services rendered.
- Conducts independent audits of non-medical records to verify billing accuracy, making decisions within designated authority to either overturn or uphold denials in a timely manner.
- Generates and communicates the determination to the provider using appropriate letter language and providing any necessary guideline links.
- Identifies, documents, and communicates any identified coding errors or inconsistencies, collaborating with appropriate internal department(s)to capture and track issues to ensure precise code editing and compliance.
- Completes data points within internal applications to comply with auditing requirements used within the departments of Molina.
- Actively participates in the enhancement of departmental processes to maintain alignment with current coding regulations and guidelines, while also refining internal procedures.
Job Qualifications
REQUIRED QUALIFICATIONS:
- At least 2 years of experience in medical coding or billing.
- Active and unrestricted Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification.
- Strong attention to detail and ability to independently read and comprehend the details of medical records.
- Comfortable working in a production-centric environment with high quality standards.
- Ability to use Microsoft Office including Outlook, Word, and Excel.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
offers a competitive benefits and compensation package. is an Equal Opportunity Employer (EOE) M/F/D/V.
Originally posted on