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

Molina Healthcare; United States; A distancia; USD 50.000 - 70.000; Jornada completa

Descripción de la vacante

Molina Healthcare, Inc. is seeking a Provider Claims Adjudicator to work remotely, with residency in Ohio. You will handle live provider claim adjustments, eligibility updates, and COBs, mainly via inbound calls, collaborating with care teams to resolve issues.

This role emphasizes accuracy, customer service, and timely processing, with standard work hours and a focus on quality service. Training and benefits are provided.

Formación

• At least 2 years in a clerical role in a claims or customer service setting in a managed care environment.
• Research and data analysis skills.
• Strong organizational skills and attention to detail.
• Time-management skills to handle multiple tasks to meet deadlines.
• Customer service experience.
• Effective verbal and written communication.
• Proficiency with Microsoft Office and related software.

Responsabilidades

• Provides support for provider claims adjudication, addressing claim issues and researching resolutions.
• Supports resolution of provider claims issues, analyzing systems and coordinating with billing to resolve.
• Collaborates with enrollment, provider information management, benefits configuration and claims teams to address issues.
• Responds to incoming calls from providers regarding claims inquiries with excellent customer service.
• Assists in reviews of state and federal complaints related to claims.
• Collaborates with internal departments to determine appropriate resolution of claims issues.
• Researches claim tracers, adjustments, and resubmissions of claims.
• Adjudicates or readjudicates high volumes of claims in a timely manner.
• Identifies defect patterns and communicates potential solutions to leadership.
• Meets claims department quality and production standards.
• Supports initiatives to improve claims efficiency.
• Completes basic claims projects as assigned.

Conocimientos

Clerical experience

Research & data analysis

Organizational skills

Time-management

Customer service

Verbal & written communication

Microsoft Office proficiency

Herramientas

Salesforce

QNXT

PEGA

Claim Shark

Microsoft Office

Descripción del empleo

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