Claims Examiner – Adjudication & Fraud Detection

Molina Talent Acquisition; Florida; Sur place; USD 42 000 - 52 000; Plein temps

Avantages offerts par ce poste

Competitive benefits

Equal opportunity employer

Résumé du poste

Molina Healthcare is seeking a Claims Examiner Support to assist in adjudication evaluation, ensuring accurate coding and detecting potential fraud or errors. You will manage a caseload, gather records, and support investigations to resolve claims efficiently.

The role emphasizes data entry, organizational skills, and strong communication, with MS Office proficiency and a focus on meeting quality and production standards in a managed care environment.

Qualifications

• At least 1 year of experience in a clerical role in a claims, and/or customer service setting - preferably in managed care, or equivalent combination of relevant education and experience.
• Data entry and research 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.

Responsabilités

• Evaluates the adjudication of claims using standard principles, and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors.
• Manages a caseload of claims - procures all medical records and statements that support the claim.
• Makes recommendations for further investigation and/or resolution of claims.
• Reduces defects through proactive identification of error issues as it relates to pre-payment of claims through adjudication/trend identification, and recommends solutions to resolve issues.
• Meets claims department quality and production standards.
• Supports claims department initiatives to improve overall claims function efficiency.
• Completes basic claims projects as assigned.

Connaissances

Data entry

Research skills

Organizational skills

Time-management

Customer service

Verbal and written communication

Outils

Microsoft Office

Description du poste

Molina Healthcare is seeking a Claims Examiner Support to assist in adjudication evaluation, ensuring accurate coding and detecting potential fraud or errors. You will manage a caseload, gather records, and support investigations to resolve claims efficiently.

The role emphasizes data entry, organizational skills, and strong communication, with MS Office proficiency and a focus on meeting quality and production standards in a managed care environment.