Adjudicator, Provider Claims (LTSS Call Center)

Molina Healthcare • Houston, TX • 13h ago

Job Description

Job Summary

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

Knowledge/Skills/Abilities

Facilitates the resolution of claims issues, including incorrectly paid claims, by working with operational areas and provider billings and analyzing the systems.

This role is 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 the 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.

Knowledgeable in systems utilized:

QNXT

Pega

Verint

Kronos

Microsoft Teams

Video Conferencing

Others as required by line of business or state

Job Function

Provides customer support and stellar service to assist Molina providers with claims inquiries. Leads and resolves issues and addresses needs appropriately and effectively, while demonstrating Molina values in their actions. Responsible for effectively managing and documenting calls and responding to providers regarding issues with claims and inquiries. Handles escalated inquiries, complex provider claims payments, records, and provides counsel to providers. Helps to mentor and coach Provider Claims Adjudicators.

Job Qualifications

REQUIRED EDUCATION:

Associate's Degree or equivalent combination of education and experience;

REQUIRED EXPERIENCE:

2-3 years customer service, claims, provider and investigation/research experience. Outcome focused and knowledge of multiple systems.

1+ years of claims research and/or issue resolution or analysis of reimbursement methodologies within the managed care health care industry

PREFERRED EDUCATION:

Bachelor's Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

4 years customer service, claims, provider and investigation/research experience.

LTSS claims experience

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in a home or office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $21.16 - $38.37 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Go to Apply

Adjuster, Claims (Remote)

Molina Healthcare • Houston, TX • 12h ago

Finance, Accounting & Banking

JOB DESCRIPTION Job Summary Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog...

12h ago

Go to Apply

Account Underwriter - Management Liability

Travelers Insurance Company • Houston, TX • 13h ago

Finance, Accounting & Banking

Who Are We? Taking care of our customers, our communities and each other. That's the Travelers Promise. By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the...

13h ago

Go to Apply

US Finance Business Consulting - Manager

EY • Houston, TX • 19h ago

Finance, Accounting & Banking

Location: Anywhere in Country At EY, we're all in to shape your future with confidence. We'll help you succeed in a globally connected powerhouse of diverse teams and take your career wherever you want it to go. Join EY...

19h ago

Go to Apply

HDG #841 - ITTS - International Corporate Tax Advisory Senior - FY26

EY • Houston, TX • 19h ago

Finance, Accounting & Banking

Location: San Jose, Boston, McLean, Philadelphia, Hoboken, Iselin, Jericho, New York City, Stamford, Los Angeles, San Francisco, Seattle, Portland, Phoenix, Chicago, Milwaukee, St. Louis, Kansas City, Detroit, Grand Rapi...

19h ago

Go to Apply

Bookkeeping and Accounting

Swift Merchants, LLC • Houston, TX • 23h ago

Finance, Accounting & Banking

Operate computers programmed with accounting software to record, store, and analyze information. Receive, record, and bank cash, checks, and vouchers. Perform financial calculations, such as amounts due, interest charges...

23h ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.