Adjudicator, Provider Claims-on the phone

Molina Healthcare; Northern (KY); Hybrid; USD 22,000 - 44,000; Full time

Job summary

Molina Healthcare is seeking a detail‑oriented claims support professional in the United States, Kentucky region. The role involves addressing provider claim issues, researching and resolving discrepancies, and ensuring timely adjudication and communication with providers.

The candidate will collaborate across departments, manage multiple tasks, and uphold quality standards while contributing to process improvements within the claims function.

Qualifications

• At least 2 years of clerical experience in a claims or customer service setting.
• Experience in provider claims investigation/research/resolution/reimbursement analysis.
• Strong research and data analysis skills.
• Excellent organizational skills and attention to detail.
• Effective verbal and written communication; proficient in Microsoft Office.

Responsibilities

• Provide support for resolution of provider claims issues, including incorrect payments.
• Collaborate with enrollment, provider information management, benefits configuration and claims processing teams.
• Respond to provider calls regarding claims inquiries and document interactions.
• Assist in reviews of state and federal complaints related to claims.
• Research tracers, adjustments, and resubmissions of claims.
• Adjudicate or readjudicate high volumes of claims in a timely manner.

Skills

Data analysis

Customer service

Time management

Written and verbal 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

Pay Range: $15.58 - $31.97 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.