Senior Examiner, Claims(Florida)

Molina Healthcare; Florida; On-site; USD 50,000 - 75,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare is seeking a Senior Claims Examiner in the United States (Florida) to provide senior-level support for claims examination, including evaluation of adjudication for incorrect coding, abuse, fraud, waste, overpayments, and processing errors.

The role requires managing a caseload, procuring medical records, making recommendations for investigation or resolution, and ensuring compliance with regulations across multiple lines of business.

Qualifications

• At least 2 years of experience in claims, and/or customer service in a clerical setting.
• Research and data entry skills.
• Strong organizational skills and attention to detail.
• Excellent time-management and ability to manage multiple tasks to deadlines.
• Customer service experience with effective verbal and written communication.
• Proficiency in Microsoft Office suite and related software.

Responsibilities

• Evaluates adjudication of claims to identify incorrect coding, abuse, fraud, waste, and processing errors.
• Manages a caseload of claims and procures medical records and supporting statements.
• Makes recommendations for investigation and resolution of claims.
• Oversees reduction of defects by identifying pre-payment error issues and proposing solutions.
• Monitors medical treatment of claimants and maintains detailed notes for each claim.
• Ensures compliance with state and federal regulations on turnaround times and payments across multiple lines of business.
• Supports claims department initiatives to improve efficiency and completes assigned projects.

Skills

Research and data entry

Organizational skills

Time management

Customer service

Communication skills

Microsoft Office

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