Senior Claims Examiner - Fraud & Compliance

Molina Healthcare; Northern (KY); Hybrid; USD 18,000 - 40,000; Full time

Job summary

Molina Healthcare is seeking a senior-level claims examiner to provide expert support in adjudication, documentation, and investigation of claims. The role emphasizes identifying coding errors, abuse, fraud, and processing weaknesses while maintaining meticulous case records.

YOU will handle a diverse caseload, procure medical records, and recommend investigations or resolutions. Strong organization, data entry, and MS Office proficiency are essential for meeting strict timelines and quality

Qualifications

• At least 2 years of experience in claims, and/or customer service experience in a clerical role - 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.
• Customer service experience.
• 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, 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.
• 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 experience

Research and data entry

Organizational skills

Time management

Customer service

Communication skills

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a senior-level claims examiner to provide expert support in adjudication, documentation, and investigation of claims. The role emphasizes identifying coding errors, abuse, fraud, and processing weaknesses while maintaining meticulous case records.

YOU will handle a diverse caseload, procure medical records, and recommend investigations or resolutions. Strong organization, data entry, and MS Office proficiency are essential for meeting strict timelines and quality