Lead Adjudicator, Provider Claims( Remote)-closing shift

Molina Healthcare; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Molina Healthcare in the United States is seeking a lead-level Provider Claims Adjudicator to oversee adjudication activities, respond to providers with issue resolution, and drive accurate claim decisions.

You will coordinate workflow, manage escalations, and mentor staff while partnering with other teams to improve processes and provider satisfaction.

This role requires strong analytical and problem-solving skills, attention to detail, and a commitment to high-quality customer service.

Qualifications

• Minimum 3 years as a Provider Claims Adjudicator.
• Experience in claims adjusting and customer service.
• Strong problem solving, research and resolution abilities.

Responsibilities

• Coordinate workflow and staffing of day-to-day claims adjudication activities.
• Manage escalations within the claims department to closure.
• Perform daily claims troubleshooting to support provider claims.
• Lead quality improvement efforts to enhance claims processes.
• Provide provider claims expertise and training to staff.
• Identify trends and suggest improvements to claims quality.

Skills

Analytical skills

Problem solving

Attention to detail

Customer service

Research and resolution

Education

Associate’s Degree or equivalent

Bachelor’s Degree or equivalent

Job description

JOB DESCRIPTION Job 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.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V