Senior Claims Examiner: Detect & Resolve Complex Billing

Molina Healthcare Inc; United States; On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a senior claims examiner-level professional to support adjudication, identify coding issues, and detect fraud across multiple lines of business. The role involves managing a caseload, securing medical records, and driving prompt resolutions.

You will maintain detailed documentation, adhere to state and federal regulations, and collaborate with teams to improve accuracy and efficiency in claims processing.

Qualifications

• 2+ years of claims and/or clerical customer service experience, preferably in managed care.
• Strong data entry and research skills.
• Excellent organizational skills with attention to detail.
• Ability to manage multiple tasks and meet deadlines.
• Customer service experience and effective communication skills.
• Proficiency with Microsoft Office and related software.

Responsibilities

• Evaluates adjudication of claims to identify incorrect coding and fraud.
• Manages a caseload of claims; procures medical records and supporting statements.
• Makes recommendations for further investigation or resolution.
• Reduces defects by identifying error issues in pre-payment adjudication and suggesting solutions.
• Meets state and federal regulations on turnaround times and payments across multiple LOBs.
• Maintains meticulous notes and records for each claim.
• Supports claims department initiatives to improve efficiency.
• Completes claims-related projects as assigned.

Skills

Experience in claims processing

Customer service

Research and data entry

Organizational skills

Time management

Verbal and written communication

Microsoft Office proficiency

Attention to detail

Preferred managed care exposure

Team collaboration

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a senior claims examiner-level professional to support adjudication, identify coding issues, and detect fraud across multiple lines of business. The role involves managing a caseload, securing medical records, and driving prompt resolutions.

You will maintain detailed documentation, adhere to state and federal regulations, and collaborate with teams to improve accuracy and efficiency in claims processing.