Claims Integrity & Adjudication Auditor

Molina Healthcare Inc; Town of Florida (NY); On-site; USD 42,000 - 58,000; Full time

Job summary

Molina Healthcare provides support for claims examination activities, evaluating adjudication to identify incorrect coding, abuse and fraudulent billing, waste, overpayments, and processing errors.

The role manages a caseload of claims, procures medical records, and makes recommendations for investigation or resolution. Ideal candidates have 1 year of clerical experience in claims or customer service within managed care, strong data entry, organizational and communication skills.

Qualifications

• Data entry and research skills.
• Organizational skills and attention to detail.
• Time-management skills and ability to manage multiple tasks to meet deadlines.
• Customer service experience.
• Effective verbal and written communication skills.
• Proficiency in Microsoft Office and applicable software.

Responsibilities

• Evaluate the adjudication of claims to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors.
• Manage a caseload of claims and procure all medical records and statements supporting the claim.
• Make recommendations for further investigation and/or resolution of claims.
• Identify and reduce defects by pre-payment adjudication trend analysis and propose solutions.
• Meet claims department quality and production standards.
• Support claims department initiatives to improve overall claims function efficiency.
• Complete basic claims projects as assigned.

Skills

Data entry

Research

Time management

Organizational skills

Attention to detail

Customer service

Verbal communication

Written communication

Tools

Microsoft Office

Job description

Molina Healthcare provides support for claims examination activities, evaluating adjudication to identify incorrect coding, abuse and fraudulent billing, waste, overpayments, and processing errors.

The role manages a caseload of claims, procures medical records, and makes recommendations for investigation or resolution. Ideal candidates have 1 year of clerical experience in claims or customer service within managed care, strong data entry, organizational and communication skills.