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

Molina Healthcare, Inc.; Ohio; Remote; USD 23,000 - 44,000; Full time

Job summary

Molina Healthcare, Inc. is hiring a Provider Claims Adjudicator. This remote role requires the candidate to reside in Ohio and handle live provider calls to adjudicate and adjust claims.

Responsibilities include researching issues, resolving mispaid claims, and coordinating with billing and provider teams. The role emphasizes customer service and accurate documentation in a fast-paced environment.

Qualifications

• 2+ years in a claims, customer service, or clerical role within a managed care org.
• Strong research and data analysis skills.
• Excellent organizational, time-management, and detail orientation.

Responsibilities

• Respond to provider inquiries and resolve claim issues; document interactions.
• Analyze mispaid claims and coordinate with billing teams for resolution.
• Collaborate with enrollment, benefits, and claims teams to address issues.
• Adjudicate high volumes of claims promptly and meet quality standards.
• Support in reviews of state and federal complaints related to claims.
• Identify defect trends and communicate solutions to leadership.

Skills

MCO claims

Call center

Billing appeals

Provider service

Salesforce

QNXT

PEGA

Claim Shark

Tools

Salesforce

QNXT

PEGA

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

Pay Range: $16.4 - $31.97 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.