Senior Provider Claims Adjudicator & Team Lead

Molina Healthcare; United States; Remote; USD 65,000 - 95,000; Full time

Job summary

Remote Jobs is seeking a lead-level Provider Claims Adjudicator to oversee day-to-day adjudication activities, respond to providers, and ensure timely, accurate resolution of claims.

The role emphasizes staffing coordination, escalation management, quality improvement, and training support. A strong background in provider claims adjudication, customer service, and analytical problem solving is essential.

Qualifications

• Associate’s Degree or equivalent combination of education and experience.
• Minimum 3 years as Provider Claims Adjudicator.
• Experience in claims adjusting and customer service, problem solving, critical thinking, research and resolution skills.

Responsibilities

• Coordinates workflow and staffing of day-to-day claims adjudication activities, and assigns and monitors work of staff to ensure adherence to productivity and quality standards.
• Manages escalations within the claims department by ensuring accountability, urgency, communication and follow-through to closure.
• Performs daily claims troubleshooting procedures to support provider claims function as needed.
• Participates in or leads quality improvement efforts to improve claims processes and/or policies.
• Serves as provider claims subject matter expert; provides feedback to team and facilitates training as needed.
• Reviews claims deficiencies and makes recommendations to increase efficiencies and provider satisfaction.
• Sets standard with team for exemplary customer service delivery and ensures the team is meeting established claims metrics and compliance measures.
• Partners with stakeholders and leaders in other functions to coordinate provider claims-related problem-solving in an effective and timely manner.
• Provides technical claims expertise to peers and handles complex provider calls.
• Assists with training needs of claims department staff.
• Assists leadership with claims staff development.
• Recognizes trends and patterns in call and claims types and engages leadership with suggested solutions.
• Meets department quality and production standards.
• Supports all claims department initiatives to improve overall efficiency.
• Completes claims projects as assigned.

Skills

Provider claims adjudication

Customer service

Problem solving

Critical thinking

Research and resolution

Attention to detail

Analytical skills

Education

Associate’s Degree or equivalent combination of education and experience

Bachelor’s Degree or equivalent combination of education and experience

Job description

Remote Jobs is seeking a lead-level Provider Claims Adjudicator to oversee day-to-day adjudication activities, respond to providers, and ensure timely, accurate resolution of claims.

The role emphasizes staffing coordination, escalation management, quality improvement, and training support. A strong background in provider claims adjudication, customer service, and analytical problem solving is essential.