**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, c...