Adjudicator, Provider Claims

Molina Healthcare; Kentucky; On-site; USD 36,000 - 48,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare in Kentucky seeks a Claims Adjudication Support professional to assist in resolving provider claims, researching issues, and ensuring accurate reimbursements. The role collaborates with enrollment, information management, and processing teams to ensure accurate claim resolution.

The ideal candidate has experience in provider claims investigation and strong data analysis skills, with a focus on customer service and precise documentation.

Qualifications

• Experience in provider claims investigation/research/resolution within a managed care organization or equivalent
• Strong research and data analysis abilities
• Excellent organizational skills and attention to detail
• Effective time-management to handle multiple tasks and deadlines
• Customer service experience and communication skills
• Proficiency with Microsoft Office applications and related software

Responsibilities

• Provide support for resolution of provider claims issues and analyze systems to facilitate resolution.
• Collaborate with enrollment, information management, benefits configuration, and claims processing teams to address provider claim issues.
• Respond to providers regarding claims inquiries with strong customer service and document interactions.
• Assist in reviews of state and federal complaints related to claims.
• Coordinate with internal departments to determine appropriate resolution of claims issues.
• Research claims tracers, adjustments, and resubmissions of claims.
• Adjudicate or readjudicate high volumes of claims in a timely manner.
• Identify and communicate claims error issues and potential solutions to leadership to reduce defects.
• Meet claims department quality and production standards.
• Support claims department initiatives to improve efficiency.
• Complete basic claims projects as assigned

Skills

Research & data analysis

Organizational skills

Time management

Customer service

Verbal & written communication

Microsoft Office proficiency

Tools

Microsoft Office

Job description

Job Summary

Provides support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating and ensuring appropriate resolution of claims.

Essential Job Duties

• Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas/provider billing to facilitate resolution.
• Collaborates with the member enrollment, provider information management, benefits configuration and claims processing teams to appropriately address provider claim issues.
• Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions.
• Assists in reviews of state and federal complaints related to claims.
• Collaborates with other internal departments to determine appropriate resolution of claims issues.
• Researches claims tracers, adjustments, and resubmissions of claims.
• Adjudicates or readjudicates high volumes of claims in a timely manner.
• Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership.
• Meets claims department quality and production standards.
• Supports claims department initiatives to improve overall claims function efficiency.
• Completes basic claims projects as assigned.

Required Qualifications

• At least 2 years of experience in a clerical role in a claims, and/or customer service setting, including experience in provider claims investigation/research/resolution/reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience.
• Research and data analysis skills.
• Organizational skills and attention to detail.
• Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Customer service experience.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V