Adjudicator, Provider Claims (Inbound Call Center) Remote in Ohio
About The Position
Molina Healthcare is hiring a Provider Claims Adjudicator for a remote position. Candidates must live in Ohio. The role involves heavy inbound phone calls from providers and helping them with live claim adjustments, eligibility updates, and coordination of benefits (COBs). The Adjudicator supports provider claims activities by responding to claim questions, researching and investigating issues, and ensuring appropriate resolution. The role also adjudicates or readjudicates high volumes of claims, documents provider interactions, helps address complaints, and works with internal teams to resolve claims issues and improve claims operations.
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 in Microsoft Office suite and applicable software programs.
- Must live in Ohio.
Nice To Haves
- Managed care/MCO claims experience.
- Call center claims experience.
- Experience with billing, appeals, and grievances.
- Provider customer service and/or member experience.
- Experience with Salesforce, QNXT, PEGA, or Claim Shark.
Responsibilities
- Respond to providers about claim issues and research, investigate, and ensure appropriate resolution.
- Support resolution of provider claims issues, including incorrectly paid claims, 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.
- Respond to incoming provider calls regarding 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 resolution of claims issues.
- Research claims tracers, adjustments, and resubmissions.
- Adjudicate or readjudicate high volumes of claims in a timely manner.
- Identify and communicate claims errors and potential solutions to leadership to support defect reduction.
- Meet claims department quality and production standards.
- Support initiatives to improve claims function efficiency.
- Complete basic claims projects as assigned.
Benefits
- Competitive benefits and compensation package.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
