Adjudicator, Provider Claims-On The Phone

Molina Healthcare Inc; Cincinnati (OH); On-site; USD 42,000 - 52,000; Full time

Job summary

Molina Healthcare, Inc. is seeking a claims support professional in Cincinnati, OH to assist with provider claims adjudication. You will address claim issues, research resolutions, and ensure timely processing while delivering excellent customer service.

The role emphasizes collaboration across enrollment, provider information management, and benefits configuration teams, with a focus on accuracy, efficiency, and regulatory compliance. Equal opportunity employer.

Qualifications

• 2+ years in a clerical claims or customer service role in a managed care setting.
• Experience researching and resolving provider claim issues.
• Strong data analysis, organization and attention to detail.

Responsibilities

• Support resolution of provider claims issues, including incorrect payments.
• Collaborate with enrollment, provider information, benefits, and claims teams to address issues.
• Respond to provider calls about claim inquiries and document interactions.
• Assist in reviews of state and federal complaints related to claims.
• Research tracers, adjustments, and resubmissions of claims.
• Adjudicate/readjudicate high volumes of claims promptly.
• Identify and communicate error issues and potential solutions to leadership.
• Meet claims department quality and production standards.
• Support initiatives to improve claims function efficiency.
• Complete basic claims projects as assigned.

Skills

Claims investigation

Data analysis

Organizational skills

Time management

Customer service

Verbal and written communication

Microsoft Office

Tools

Microsoft Office

Job description

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.
• 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 proficiency.

Molina Healthcare offers a competitive benefits and compensation package.

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