Adjudicator, Provider Claims-on the phone

Molina Healthcare; Kentucky; On-site; USD 36,000 - 48,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare is seeking a claims support professional in the United States (Kentucky) to assist with provider claims adjudication and issue resolution. You will address inquiries, analyze claims problems, and collaborate across departments to ensure timely, accurate resolutions.

The role emphasizes attention to detail, strong communication, and adherence to established quality standards, with opportunities to contribute to claims process improvements within a supportive team environment.

Qualifications

• 2+ years in a clerical claims or customer service role within managed care or similar setting.
• Strong research and data analysis capabilities.
• Detail-oriented with solid organizational skills and ability to manage multiple tasks.

Responsibilities

• Support resolution of provider claims issues and investigate incorrect payments.
• Collaborate with enrollment, provider information, benefits configuration, and claims teams.
• Handle provider inquiries via calls and document interactions.
• Assist in reviews of state and federal complaints related to claims.
• Coordinate with internal departments to resolve claims issues.
• Research tracers, adjustments, and resubmissions of claims.
• Adjudicate or readjudicate high volumes of claims promptly.
• Identify and communicate defect trends and potential solutions to leadership.
• Meet department quality and production standards.
• Support initiatives to improve claims function efficiency.
• Complete basic claims projects as assigned.

Skills

Research & data analysis

Customer service

Organizational skills

Time management

Verbal & written communication

Microsoft Office

Tools

Claims processing software

Job description

JOB DESCRIPTION Job Summary

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