Lead Adjudicator, Provider Claims( Remote)-closing shift

NEPSE Trading; Northern (KY); Hybrid; USD 85,000 - 110,000; Full time

Job summary

Molina Healthcare is seeking a Lead Adjudicator for Provider Claims. This remote, full-time role supervises adjudication activities, resolves complex provider claims, and drives process improvements while ensuring quality and productivity standards.

The candidate will serve as a claims SME, mentor staff, and coordinate cross-functional problem-solving to meet service levels and compliance requirements.

Qualifications

• Associate’s degree or equivalent combination of education and experience.
• Bachelor’s degree preferred.
• Minimum 3 years as a Provider Claims Adjudicator; 6+ years preferred.

Responsibilities

• Lead day-to-day claims adjudication activities and supervise staff.
• Coordinate workflow, assign and monitor work to meet standards.
• Handle escalations with accountability and timely follow-through.
• Provide training and feedback to the claims team as needed.
• Analyze claims data to improve processes and provider satisfaction.
• Collaborate with stakeholders to resolve provider claims issues.

Skills

Problem solving

Critical thinking

Research & resolution

Attention to detail

Analytical skills

Customer service

Education

Associate's degree

Bachelor's degree

Job description

# Lead Adjudicator, Provider Claims( Remote)-closing shiftMolina HealthcareUnited StatesFull timeRemoteApply by Dec 3, 2026## About the role### JOB DESCRIPTIONJob Summary Provides lead level 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 Coordinates workflow and staffing of day-to-day claims adjudication activities, and assigns and monitors work of staff to ensure adherence to productivity and quality standards. • Manages escalations within the claims department by ensuring appropriate accountability, sense of urgency, communication and follow-through to closure. • Performs daily claims troubleshooting procedures to support provider claims function as needed. • Participates in or leads quality improvement efforts to improve claims processes and/or policies. • Serves as provider claims subject matter expert; provides feedback to team and facilitates training as needed. • Reviews claims deficiencies and makes recommendations to increase efficiencies and provider satisfaction. • Sets standard with team for exemplary customer service delivery and ensures the team is meeting established claims metrics and compliance measures. • Partners with stakeholders and leaders in other functions to coordinate provider claims-related problem-solving in an effective and timely manner. • Provides technical claims expertise to peers and handles complex provider calls. • Assists with training needs of claims department staff. • Assists leadership with claims staff development. • Recognizes trends and patterns in call and claims types and engages leadership with suggested solutions. • Meets department quality and production standards. • Supports all claims department initiatives to improve overall efficiency. • Completes claims projects as assigned. Job Qualifications REQUIRED EDUCATION: Associate’s Degree or equivalent combination of education and experience REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES: Minimum 3 years as a Provider Claims Adjudicator Previous claims adjusting experience as well and customer services, problem solving, critical thinking skills and research and resolution skills.Strong attention to detail Strong analytical skills PREFERRED EDUCATION: Bachelor’s Degree or equivalent combination of education and experience PREFERRED EXPERIENCE: 6+ years previous claims adjusting and customer services experience PHYSICAL DEMANDS: Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods.Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive### benefits* and compensation package* Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V* To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board* Molina Healthcare offers a competitive benefits and compensation package* Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Originally posted on Himalayas