Senior Examiner, Claims

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

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, 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.

Required 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.

Preferred Qualifications

• Health care claims/billing experience.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V