Adjudicator, Provider Claims

Molina Talent Acquisition

79d

About The Position

The Provider Claims Adjudicator is responsible for responding to providers regarding issues with claims, coordinating, investigating and confirming the appropriate resolution of claims issues. This role will require actively researching issues to adjudicate claims and requires knowledge of operational areas and systems.

Requirements

• Associate’s Degree or equivalent combination of education and experience.
• 2-3 years customer service, claims, provider and investigation/research experience.
• 1+ years of claims research and/or issue resolution or analysis of reimbursement methodologies within the managed care health care industry.

Nice To Haves

• Bachelor’s Degree or equivalent combination of education and experience.
• 4 years of relevant experience.

Responsibilities

• Facilitates the resolution of claims issues, including incorrectly paid claims, by working with operational areas and provider billings and analyzing the systems.
• Involved in member enrollment, provider information management, benefits configuration and/or claims processing.
• Responds to incoming calls from providers regarding claims inquiries and provides excellent customer service; documents calls and interactions.
• Assists in the reviews of state or federal complaints related to claims.
• Supports other team members with several internal departments to determine appropriate resolution of issues.
• Researches tracers, adjustments, and re-submissions of claims.
• Adjudicates or re-adjudicates high volume of claims in a timely manner to ensure compliance to departmental turn-around time and quality standards.
• Manages defect reduction by supporting the identifying and communicating error issues and potential solutions to management.
• Handles special projects as assigned.
• Other duties as assigned.

What This Job Offers

• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees