Adjudicator, Provider Claims (LTSS Call Center)

Molina Healthcare • Grand Island, NE • 22h 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.

Similar Jobs

Adjuster, Claims (Remote)

Molina Healthcare • Grand Island, NE • 22h 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...

22h ago

Go to Apply

Finance Manager - REMOTE

Molina Healthcare • Grand Island, NE • 1w ago

Finance, Accounting & Banking

JOB DESCRIPTION Job Summary Responsible for analysis of financial reports, trend, and opportunities. Includes evaluation of and recommendations relating to business opportunities, investments, financial regulations, and...

1w ago

Go to Apply

Accounting Manager

Grand Island Casino Resort, LLC • Grand Island, NE • 1w ago

Finance, Accounting & Banking

Summary: ::: {#main_f2 data-value="The Accounting Manager is responsible for leading the accounting team in providing accurate, complete, and timely financial information to management. This position will manage and dire...

1w ago

Go to Apply

Adjuster, Claims - Remote

Molina Healthcare • Grand Island, NE • 2w ago

Finance, Accounting & Banking

2w ago

Go to Apply

Provider Contracts Manager

Molina Healthcare • Grand Island, NE • 4h ago

Legal & Paralegal

JOB DESCRIPTION Job Summary Negotiates National agreements with highly visible providers including integrated delivery systems, hospitals and physician groups that result in high quality, cost effective and marketable pr...

4h ago

Go to Apply

Outside Sales Representative ( B2B ) / Territory Account Manager

System One • Grand Island, NE • 1d ago

Management & Administrative

Job Title: Outside Sales Representative ( B2B ) / Territory Account Manager Location: Grand Island, Nebraska Type: Direct Hire For immediate consideration, please connect with me on LinkedIn at https://www.linkedin.com/i...

1d ago

Go to Apply

Hotel Guest Service Rep

Kinseth Hospitality Companies • Grand Island, NE • 1d ago

Retail & Hospitality

What we offer: Health, Dental, Vision and other benefits available after 60 days DailyPay 401k Paid Training Paid PTO Referral program Discounts at all Kinseth Hotel Corporation hotels and restaurants SUMMARY Provides cu...

1d ago

Go to Apply

Registered Nurse - Clinical Nurse Educator/Safe Patient Handling & Mobility

Veterans Affairs, Veterans Health Administration • Grand Island, NE • 1d ago

Hospital & Medical

Summary Join our team as a Clinical Nurse Educator/Safe Patient Handling & Mobility Registered Nurse, where you will be responsible for providing expert, evidence-based education to nursing staff within clinical and...

1d ago

Go to Apply

Retail Stocking Supervisor

Harbor Freight Tools • Grand Island, NE • 1d ago

Retail & Hospitality

168066BRPosting Title:Retail Stocking SupervisorJob Description: A Supervisor (full-time) is a valued member of a high performing team who is empowered & equipped to do their job. You will know why your work matters...

1d ago

Go to Apply

Deli Production Team Member

Pilot Company • Wood River, NE • 1d ago

Retail & Hospitality

Company Description Pay Rates Starting between: $13.50 - $17.85 / hour Are you passionate about team building, customer service, and meeting new people? Pilot Company offers a dynamic environment where no two days are th...

1d 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.