Senior Examiner, Claims(Florida)

Molina Talent Acquisition; Florida; On-site; USD 42,000 - 62,000; Full time

Job summary

Molina Healthcare is seeking a claims examiner to provide senior support in evaluating adjudication of claims, identifying coding issues, abuse and fraudulent billing, and resolution of processing errors. The role involves procuring medical records, maintaining detailed notes, and ensuring regulatory compliance across multiple lines of business.

Qualifications include 2+ years in claims or clerical roles, strong data entry and communication skills, and proficiency with the Microsoft Office

Qualifications

• 2+ years of experience in claims or clerical role, preferably in managed care.
• Demonstrated research and data entry skills.
• Strong organizational skills and attention to detail.
• Proven time-management to handle multiple tasks and deadlines.
• Customer service experience is required.
• Effective verbal and written communication skills.
• Proficiency with Microsoft Office and related software.

Responsibilities

• Evaluate adjudication of claims using standard principles and regulations to identify issues.
• Procure all medical records and statements to support a claim.
• Recommend investigations and resolutions for claims.
• Oversee reduction of defects related to pre-payment adjudication and suggest solutions.
• Monitor medical treatment and maintain meticulous records for each claim.
• Manage a caseload of complex claims and related documentation.
• Ensure compliance with state and federal turnaround times and payment regulations.
• Support claims department initiatives to improve efficiency and complete assigned projects.

Skills

Research

Data entry

Organizational skills

Time management

Customer service

Communication skills

Microsoft Office

Tools

Microsoft Office Suite

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, 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.
• 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