Examiner, Claims (Remote)

Molina Healthcare•Long Beach, CA

3d•Remote

About The Position

Provides support for claims examination activities by evaluating claim adjudications to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors. The role manages a caseload, obtains medical records and supporting statements, and recommends further investigation or claim resolution. It also helps reduce defects by identifying pre-payment errors and trends and recommending solutions, meets claims department quality and production standards, supports initiatives to improve claims efficiency, and completes basic claims projects as assigned.

Requirements

At least 1 year of experience in a clerical role in a claims and/or customer service setting, preferably in managed care, or an equivalent combination of relevant education and experience.
Data entry and research 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 suite and applicable software programs.

Nice To Haves

Health care claims/billing experience.

Responsibilities

Evaluate claim adjudications using standard principles and state-specific regulations to identify incorrect coding, abuse, fraudulent billing practices, waste, overpayments, and claims processing errors.
Manage a caseload of claims and obtain medical records and statements that support each claim.
Recommend further investigation and/or resolution of claims.
Proactively identify pre-payment claim errors and trends, recommend solutions, and help reduce defects.
Meet claims department quality and production standards.
Support initiatives to improve the overall efficiency of the claims function.
Complete basic claims projects as assigned.