Adjudicator, Provider Claims-On The Phone-Ohio

Molina Healthcare • Kentucky, Kentucky • 2d 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

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

PFS Insurance Follow-up Rep AHCCCS State Denials

Banner Health • Kentucky, Kentucky • 5d ago

Finance, Accounting & Banking

Department Name: Amb Billing & Follow Up Work Shift: Day Job Category: Revenue Cycle Estimated Pay Range: $17.58 - $26.36 / hour, based on location, education, & experience. In accordance with State Pay Transpare...

5d ago

Go to Apply

Adjudicator, Provider Claims (LTSS Call Center)

Molina Healthcare • Kentucky, Kentucky • 2w ago

Finance, Accounting & Banking

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. Th...

2w ago

Go to Apply

Adjuster, Claims (Remote)

Molina Healthcare • Kentucky, Kentucky • 2w 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...

2w ago

Go to Apply

Finance Manager - REMOTE

Molina Healthcare • Kentucky, Kentucky • 3w 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...

3w ago

Go to Apply

Analyst V, Supply Chain Management

American Red Cross • Kentucky, Kentucky • 20h ago

Management & Administrative

Please use Google Chrome or Mozilla Firefox when accessing Candidate Home. By joining the American Red Cross you will touch millions of lives every year and experience the greatness of the human spirit at its best. Are y...

20h ago

Go to Apply

Construction Project Manager

GeoStabilization International • Kentucky, Kentucky • 2d ago

Trucking & Construction

Overview Who is GeoStabilization International®? GeoStabilization International® (GSI) develops and installs innovative solutions that protect people and infrastructure from the dangers of geohazards. We specialize in em...

2d ago

Go to Apply

Client Executuve - DoD

TekSynap • Kentucky, Kentucky • 2d ago

Responsibilities & Qualifications This is a senior-level, customer-facing field sales role responsible for managing strategic sales activities within the Department of Defense, with a focus on IT-related solutions. T...

2d ago

Go to Apply

AVP, Medicare Duals Optimization (REMOTE)

Molina Healthcare • Kentucky, Kentucky • 3d ago

Job Description Job Summary Provides leadership to a team that is responsible for strategy, process improvements, and operational support to advance the goals and objectives of the Integrated Duals program. Supports inte...

3d ago

Go to Apply

Remote - Luxury Sales Consultant

Teleperformance USA • Kentucky, Kentucky • 4d ago

Management & Administrative

Category : Client Operations About TP TP is a global, digital business services company. We deliver the most advanced, digitally powered business services to help the world's best brands streamline their business in mean...

4d ago

Go to Apply

Supervisor, HCS Operations Support

Molina Healthcare • Kentucky, Kentucky • 4d ago

JOB DESCRIPTION Job Summary Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum...

4d 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.