Lead Provider Claims Adjudicator & Quality Champion

Molina Healthcare; Northern (KY); Hybrid; USD 25,000 - 53,000; Full time

Job summary

Molina Healthcare is seeking a lead-level provider claims adjudication specialist to oversee day-to-day activities and staff performance in a healthcare claims department.

You will address provider claim issues, research resolutions, and drive process improvements while ensuring high-quality service and adherence to metrics. This role emphasizes collaboration across teams and training of staff.

Qualifications

• Associate’s Degree or equivalent combination of education and experience.
• Minimum 3 years as a Provider Claims Adjudicator.
• Bachelor’s Degree or equivalent combination of education and experience (preferred).
• Experience in claims adjusting and customer service, problem solving and research.

Responsibilities

• Coordinates workflow and staffing of day-to-day claims adjudication activities and assigns and monitors work to ensure productivity and quality.
• Manages escalations within the claims department to ensure accountability and timely closure.
• Performs daily claims troubleshooting procedures to support provider claims function.
• Participates in quality improvement efforts to improve claims processes and policies.
• Serves as provider claims subject matter expert and facilitates training.
• Reviews claims deficiencies and recommends improvements to increase efficiency and provider satisfaction.
• Sets standards for exemplary customer service and monitors claims metrics and compliance.
• Partners with stakeholders to coordinate provider claims-related problem-solving.
• Provides technical claims expertise to peers and handles complex provider calls.
• Assists with training needs of claims staff and leadership development.
• Recognizes trends and proposes solutions for call and claims patterns.
• Meets department quality and production standards and supports initiatives to improve efficiency.
• Completes claims projects as assigned.

Skills

Claims adjudication

Customer service

Problem solving

Critical thinking

Research and resolution

Education

Associate’s degree

Bachelor’s degree

Job description

Molina Healthcare is seeking a lead-level provider claims adjudication specialist to oversee day-to-day activities and staff performance in a healthcare claims department.

You will address provider claim issues, research resolutions, and drive process improvements while ensuring high-quality service and adherence to metrics. This role emphasizes collaboration across teams and training of staff.