Adjudicator, Provider Claims - Remote (Inbound Provider Calls)

Molina Healthcare•Long Beach, CA

3d•Remote

About The Position

The Adjudicator, Provider Claims supports provider claims adjudication by responding to provider inquiries, researching claim issues, and ensuring appropriate resolution. The position handles inbound calls from providers and works with internal operational teams to investigate claims, correct errors, and improve claims processing efficiency. The schedule is Monday through Friday during the closing shift: 12:00 p.m.–8:30 p.m. Eastern, 11:00 a.m.–7:30 p.m. Central, 10:00 a.m.–6:30 p.m. Mountain, or 9:00 a.m.–5:30 p.m. Pacific.

Requirements

At least 2 years of experience in a clerical role in claims and/or customer service, including provider claims investigation, research, resolution, or reimbursement methodology analysis within a managed care organization, or an equivalent combination of relevant education and experience.
Research and data analysis skills.
Organizational skills and attention to detail.
Time-management skills and the ability to manage simultaneous projects and tasks to meet internal deadlines.
Customer service experience.
Effective verbal and written communication skills.
Proficiency with Microsoft Office and applicable software programs.

Responsibilities

Support the resolution of provider claims issues, including incorrectly paid claims, by analyzing systems and collaborating with operational teams and provider billing.
Collaborate with member enrollment, provider information management, benefits configuration, and claims processing teams to address provider claim issues.
Respond to incoming provider calls about claims inquiries, provide customer service and issue resolution, and document calls and interactions.
Assist with reviews of state and federal complaints related to claims.
Work with internal departments to determine appropriate resolutions for claims issues.
Research claims tracers, adjustments, and claim resubmissions.
Adjudicate or readjudicate high volumes of claims in a timely manner.
Identify and communicate claims errors and potential solutions to leadership to reduce defects.
Meet claims department quality and production standards.
Support initiatives to improve the efficiency of the claims function.
Complete basic claims projects as assigned.