Adjudicator, Provider Claims (Inbound Call Center) Remote in Ohio

Molina Healthcare•Long Beach, OH

3d•Remote

About The Position

Molina Healthcare is hiring a Provider Claims Adjudicator to support provider claims adjudication activities. The role is remote for candidates who live in Ohio and involves heavy inbound calls from providers. The position assists providers with live claim adjustments, eligibility updates, and coordination of benefits (COB) issues. The schedule is Monday through Friday, 11:30 a.m. to 8:00 p.m. Eastern Time. The adjudicator responds to provider claim inquiries, researches and investigates claim issues, and works with internal teams to reach appropriate resolutions. The role also adjudicates or readjudicates high volumes of claims, documents provider interactions, supports complaint reviews, and contributes to claims quality, production, and efficiency initiatives.

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; an equivalent combination of relevant education and experience is also accepted.
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 suite and applicable software programs.
Must live in Ohio.

Nice To Haves

Managed care or MCO claims experience.
Call center claims experience.
Billing and Appeals and Grievances experience.
Provider customer service and/or member experience.
Experience with Salesforce, QNXT, PEGA, or Claim Shark.

Responsibilities

Respond to providers regarding claim issues and research, investigate, and ensure appropriate resolution.
Help resolve provider claim issues, including claims paid incorrectly, by analyzing systems and collaborating with operational areas and provider billing.
Collaborate with member enrollment, provider information management, benefits configuration, and claims processing teams to address provider claim issues.
Answer inbound 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.
Collaborate with internal departments to determine appropriate resolutions to claims issues.
Research claims tracers, adjustments, and claim resubmissions.
Adjudicate or readjudicate high volumes of claims in a timely manner.
Identify claims errors and potential solutions, and communicate them to leadership to support defect reduction.
Meet claims department quality and production standards.
Support initiatives to improve the efficiency of the claims function.
Complete basic claims projects as assigned.