Senior Examiner, Claims

Molina Healthcare; United States; On-site; USD 52,000 - 78,000; Full time

Job summary

Molina Healthcare is seeking a senior claims examiner to provide expert support in evaluating claim adjudication for accuracy, detecting fraud, and preventing overpayments. You will manage complex claim caseloads, procure records, and recommend investigations while ensuring compliance with regulatory standards.

The role emphasizes meticulous documentation, strong communication, and proficient use of Microsoft Office to support efficient, compliant claims processing.

Qualifications

• Research and data entry skills.
• Organizational skills and attention to detail.
• Time-management skills and ability to manage multiple projects.
• Customer service experience.
• Effective verbal and written communication skills.
• Microsoft Office suite proficiency.

Responsibilities

• Evaluates the adjudication of claims using standard principles and regulations to identify incorrect coding, abuse, and billing practices.
• Manages a caseload of claims and procures all medical records and statements that support the claim.
• Makes recommendations for further investigation and resolution of claims.
• Oversees reduction of defects by identifying error issues related to pre-payment and suggests solutions.
• Monitors the medical treatment of claimants and keeps meticulous notes for each claim.
• Meets state and federal regulatory compliance on turnaround times and claims payment for multiple lines of business.

Skills

Research and data entry

Organizational skills

Time management

Customer service

Verbal and written communication

Microsoft Office proficiency

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