Adjudicator, Provider Claims (Inbound Call Center) Remote in Ohio

Molina Healthcare, Inc.; New York (NY); Remote; USD 42,000 - 62,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare, Inc. is hiring a Provider Claims Adjudicator to support provider claims adjudication activities, including live adjustments, eligibility updates, and COBs. This is a remote role with the requirement that candidates reside in Ohio.

The position focuses on handling high volumes of inbound calls from providers and delivering accurate, timely resolutions. Ideal candidates have experience in managed care claims, call center claims, and familiarity with claims systems such as

Qualifications

• 2+ years in clerical claims or customer service within managed care, with provider claims investigation/resolution experience.
• Strong research and data analysis skills.
• Excellent organizational skills and attention to detail.
• Effective verbal and written communication skills.
• Proficiency in Microsoft Office and related software.

Responsibilities

• Provide support for provider claims adjudication, addressing claim issues and researching resolutions.
• Analyze provider claims issues and coordinate with billing/operational teams to resolve them.
• Collaborate with enrollment, benefits, and claims processing teams on provider claim issues.
• Handle incoming provider inquiries via calls with strong customer service and documentation.
• Assist in reviews of state and federal complaints related to claims.
• Coordinate with internal departments to determine resolution of claims issues.
• Review tracers, adjustments, and resubmissions of claims.
• Adjudicate or readjudicate high volumes of claims promptly.
• Support claims department initiatives to improve efficiency.

Skills

Research & Data Analysis

Customer service

Verbal & Written communication

Time management

MS Office

Tools

Salesforce

Qnxt

PEGA

Claim Shark

Job description

Molina Healthcare is hiring a Provider Claims Adjudicator. This position is remote; however candidates must live in Ohio. This position is heavy inbound phone calls from Providers. This position will be assisting Providers with live claim adjustments, eligibility updates, and/or COBs.

Hours will be Monday through Friday 1130am to 8pm EST.

Highly qualified candidates will have the following experience

• Managed Care / MCO claims experience
• Call center claims experience is highly preferred
• Billing & Appeals and Grievances
• Provider Customer service and/or Member experience
• Salesforce, QNXT, PEGA
• Claim Shark

Essential Job Duties

• 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.

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 proficient

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V