Senior Claims Examiner: Fraud & Adjudication Lead

Molina Talent Acquisition; Florida; Remote; USD 55,000 - 75,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare in Florida is seeking a Senior Claims Examiner to provide expert support in adjudication, coding accuracy, fraud prevention, and compliance with state and federal regulations. The role manages a varied caseload, procures medical records, and recommends investigations or resolutions while maintaining detailed notes and meeting turnaround times across multiple lines of business.

Strong data entry, research skills, and proficiency with the Microsoft Office suite are required to

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.

Responsibilities

• 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, and recommends 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.

Skills

Claims examination

Data entry

Organizational skills

Time management

Communication skills

Microsoft Office

Job description

Molina Healthcare in Florida is seeking a Senior Claims Examiner to provide expert support in adjudication, coding accuracy, fraud prevention, and compliance with state and federal regulations. The role manages a varied caseload, procures medical records, and recommends investigations or resolutions while maintaining detailed notes and meeting turnaround times across multiple lines of business.

Strong data entry, research skills, and proficiency with the Microsoft Office suite are required to