Adjudicator, Provider Claims - Remote (Inbound Provider Calls)

Molina Healthcare, Inc.; Oregon; Hybrid; USD 40,000 - 60,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare, Inc. is seeking a Provider Claims Support specialist to assist with adjudication of provider claims and resolution of claim issues. You will respond to provider inquiries, analyze claims data, and work cross-functionally to ensure accurate resolutions.

The role requires strong research, data analysis, organizational skills, and customer service experience, with proficiency in Microsoft Office and related software.

Qualifications

• At least 2 years of clerical experience in claims or customer service within a managed care org, or equivalent.
• Strong research and data analysis skills.
• Excellent organizational and attention to detail abilities.
• Solid time-management skills to handle multiple tasks and deadlines.
• Customer service experience with effective communication (verbal and written).
• Proficiency with Microsoft Office and related software programs.

Responsibilities

• Supports provider claims adjudication activities and resolves claim issues.
• Analyzes systems and collaborates with provider billing to facilitate resolution.
• Responds to provider calls about claims inquiries and documents interactions.
• Assists in reviews of state and federal complaints related to claims.
• Collaborates with internal departments to determine appropriate claim resolutions.
• Researches tracers, adjustments, and resubmissions of claims.
• Adjudicates or readjudicates high volumes of claims timely.
• Identifies defect trends and communicates issues and solutions to leadership.
• Meets claims department quality and production standards.
• Supports initiatives to improve overall claims function efficiency.
• Completes basic claims projects as assigned.

Skills

Data analysis

Organizational skills

Time management

Customer service

Verbal and written communication

Tools

Microsoft Office

Job description

Mon - FriClosing shift12pm -8:30pm EST11am - 7:30pm CST10am - 6:30pm MST9am - 5:30pm PST

Inbound Provider Call

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