Adjudicator, Provider Claims

Molina Healthcare; Lake Louisvilla (KY); On-site; USD 22,000 - 44,000; Full time

Job summary

Molina Healthcare is seeking a Claims Support Specialist to assist provider claims adjudication, respond to provider inquiries, and research issues to ensure timely resolutions. You will work with billing, enrollment, and claims teams to resolve complex provider claim problems and maintain high service standards.

Responsibilities include reviewing claims tracers, submitting adjustments, and reading adjudication results, while meeting quality and production goals.

Qualifications

• At least 2 years in a clerical claims or customer service role with investigation/resolution experience.
• Research and data analysis skills.
• Strong organizational skills and attention to detail.
• Ability to manage multiple projects and meet deadlines.
• Customer service experience.
• Effective verbal and written communication skills.
• Proficiency with Microsoft Office and related software.

Responsibilities

• Provide support for resolution of provider claims issues and collaborate with billing teams to facilitate resolution.
• Respond to provider inquiries with excellent customer service and document interactions.
• Review state and federal complaints related to claims.
• Collaborate with internal departments to resolve claims issues.
• Research claim tracers, adjustments, and resubmissions of claims.
• Adjudicate or readjudicate high volumes of claims promptly.
• Identify and communicate claims error issues and potential solutions to leadership.
• Meet claims department quality and production standards.
• Support initiatives to improve efficiency of the claims function.
• Complete basic claims projects.

Skills

Data analysis

Organizational skills

Time management

Customer service

Verbal and written communication

Microsoft Office

Tools

Microsoft Office

Job description

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.

• 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.

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.

• 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.

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

Pay Range: $16.4 - $31.97 / HOURLY

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.