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

Molina Healthcare, Inc.; Oregon; Hybrid; USD 48,000 - 64,000; Full time

Job summary

Molina Healthcare, Inc. is seeking a Provider Claims Adjudicator to support provider claim inquiries, adjustments, and COBs. This remote role requires residing in Ohio and involves heavy inbound calls from providers, with standard business hours EST.

You will analyze claims, assist with eligibility updates, research issues, and collaborate with claims processing teams to ensure accurate resolution while delivering excellent service.

Qualifications

• 2+ years in clerical claims or customer service roles within managed care.
• Experience with provider claims investigation, research, and resolution.
• Strong data analysis, organization, and time-management abilities.
• Excellent verbal and written communication.
• Proficiency with Microsoft Office and related software.

Responsibilities

• Respond to providers to address claim issues and research resolutions.
• Resolve provider claims issues including incorrect payments with cross-functional teams.
• Collaborate with enrollment, provider information, and benefits configuration teams.
• Handle high volumes of provider calls with excellent service and documentation.
• Review state and federal complaints related to claims.
• Research tracers, adjustments, and resubmissions.
• Adjudicate or readjudicate claims in a timely manner.
• Identify and communicate claims errors and improvement ideas to leadership.
• Strive to meet quality and production standards.
• Participate in claims initiatives to improve efficiency.
• Complete basic claims projects as assigned.

Skills

Data analysis

Organizational

Time management

Customer service

Communication

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