Senior Claims Examiner - Adjudication & Fraud Prevention

Molina Healthcare; Florida; Remote; USD 18,000 - 40,000; Full time

Job summary

Molina Healthcare is seeking a senior Claims Examiner in New York to provide expert support for claims adjudication, evaluating coding accuracy, and detecting abuse and fraudulent billing practices.

Responsibilities include managing a caseload, procuring records, recommending investigations, and ensuring regulatory compliance while driving department efficiency and process improvements.

Qualifications

• 2+ years of experience in claims, preferably in a managed care setting.
• Research and data entry skills.
• Organizational skills and attention to detail.
• Time-management skills and ability to manage simultaneous projects and tasks to meet deadlines.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software proficiency.

Responsibilities

• Evaluates the adjudication of claims using standard principles and state-specific regulations.
• Manages a caseload of claims and procures medical records and statements.
• Makes recommendations for further investigation and/or resolution of claims.
• Oversees reduction of defects by identifying error issues related to pre-payment of claims and suggests solutions.
• Identifies and recommends solutions for error issues in pre-payment of claims.
• Monitors the medical treatment of claimants and maintains meticulous notes for each claim.
• Manages a caseload of complex claims and supports documentation.
• Meets state and federal regulatory compliance requirements on turnaround times and claims payment for multiple LOBs.
• Meets department quality and production standards.
• Supports all claims department initiatives to improve efficiency.
• Completes assigned claims projects.

Skills

Experience in claims

Research

Data entry

Organizational skills

Time management

Verbal and written communication

Microsoft Office

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job Summary

Provides senior level support for claims examination activities including evaluation of adjudication of claims to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors.

Essential Job Duties

• 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.
•Oversees the reduction of defects by identifying error issues as they relate to pre-payment of claims through adjudication, andrecommends solutions to resolve issues.
•Identifies and recommends solutions for error issues as it relates to pre-payment of claims.
•Monitors the medical treatment of claimants; keeps meticulous notes and records for each claim.
• Manages a caseload of various types of complex claims - procures all medical records and statements that support the claim.
• Meets state and federal regulatory compliance regulations on turnaround times and claims payment for multiple lines of business (LOBs).
•Meets department quality and production standards.
•Supports all claims department initiatives to improve overall efficiency.
• Completes claims projects as assigned.

Required Qualifications
• At least 2 years of experience in claims, preferably in a managed care setting, or equivalent combination of relevant education and experience.
• Research and data entry skills.
• Organizational skills and attention to detail.
• Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Health care claims/billing experience.

• Medicaid Experience
  

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

Pay Range: $15 - $29.06 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.