Adjudicator, Provider Claims (Kentucky)

Molina Healthcare; Fort Thomas (KY); On-site; USD 21,000 - 44,000; Full time

Job summary

Molina Healthcare is seeking a claims adjudication support specialist in Kentucky to address provider claim issues and inquiries. You will collaborate with enrollment, information management, benefits configuration, and processing teams to resolve questions efficiently.

The role requires strong data analysis, organizational, and communication skills, along with proficiency in Microsoft Office. Prior experience in a managed care setting is preferred.

Qualifications

• 2+ years in a clerical role in claims or customer service, especially provider claims investigation or resolution.

Responsibilities

• Provide support for resolution of provider claims issues, including analyzing errors and facilitating resolution with billing teams.
• Respond to provider inquiries by phone or email, document interactions, and ensure accurate case notes.
• Review state and federal complaints related to claims and assist in investigations.
• Collaborate with internal departments to determine appropriate claim resolutions.
• Research claims tracers, adjustments, and resubmissions; readjudicate high volumes promptly.
• Identify common claim errors and suggest process improvements to leadership.

Skills

Claims research

Customer service

Data analysis

Organization

Verbal and written communication

Time management

Tools

Microsoft Office

Job description

MUST CURRENTLY RESIDE IN KENTUCKY

Provides support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating and ensuring appropriate resolution of claims.

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.
• Research 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 claim’s 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: $15.58 – $31.97 / HOURLY

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