Adjudicator, Provider Claims (Must Reside in Ohio)

Molina Healthcare • Dayton, OH • 6h 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

Accounts Payable Specialist

FECON • Lebanon, OH • 8h ago

Finance, Accounting & Banking

Job Title: Accounts Payable Specialist Manager Title: Accounting Supervisor FLSA Status: Non-Exempt, Full-Time FECON, LLC is a vegetation management equipment manufacturer located in Lebanon, Ohio near Kings Island Amuse...

8h ago

Go to Apply

Accountant, Staff

Curtiss-Wright Corporation • Fairborn, OH • 12h ago

Finance, Accounting & Banking

Accountant- Onsite Position- Defense Manufacturing We have a great opportunity for an Accountant! As our Accountant, you will be providing support to the Manager of Accounting in the areas of Accounts Receivable/Accounts...

12h ago

Go to Apply

Accounting Specialist

RELX INC • Dayton, OH • 12h ago

Finance, Accounting & Banking

Are you interested in delivering best-in-class programs? Do you enjoy collaborating cross-functionally to deliver on common goals? About our Team Intelligize is the leading provider of analytical tools for SEC compliance...

12h ago

Go to Apply

Consumer Banker IV (Troy)

First Financial Bank • Troy, OH • 2d ago

Finance, Accounting & Banking

We do the right things, right now. We do them in a way that is relevant to our clients. Become a part of our history as it continues to be written! If you are interested and qualified for this role, we invite you to appl...

2d ago

Go to Apply

Billing & Revenue Trainer

Dayton Power & Light Company • Dayton, OH • 2d ago

Finance, Accounting & Banking

Are you ready to be part of a company that's not just talking about the future, but actively shaping it? Join The AES Corporation (NYSE: AES), a Fortune 500 company that's leading the charge in the global energy revoluti...

2d ago

Go to Apply

Program Manager, Enrollment Accounting

Molina Healthcare • Dayton, OH • 3d ago

Finance, Accounting & Banking

JOB DESCRIPTION Job Summary Responsible for internal business projects and programs involving department or cross-functional teams of subject matter experts, delivering products through the design process to completion....

3d ago

Go to Apply

Senior Indirect Tax Accountant

Baker Concrete Construction, Inc. • Monroe, OH • 3d ago

Finance, Accounting & Banking

Req ID: 6805 Travel: Up to 15% Number of Openings:1 Achieve more in your career with the nation's leading specialty concrete contractor. At Baker Construction, you'll be part of a team that prioritizes people, invests in...

3d ago

Go to Apply

Accounts Payable Specialist

Wilmer Cutler Pickering Hale and Dorr LLP • Miamisburg, OH • 3d ago

Finance, Accounting & Banking

Tracking Code 2271-437 Job Description WilmerHale is a leading, full-service international law firm with 1,000 lawyers located throughout 12 offices in the United States, Europe and Asia. Our lawyers work at the intersec...

3d ago

Go to Apply

Tax Manager, State Income and Franchise - Multistate

Deloitte • Dayton, OH • 4d ago

Finance, Accounting & Banking

Are you a strategic and creative Multistate Tax professional who loves solving complex state and local tax issues? Are you intrigued by the tax considerations specific to investment management, private equity, real estat...

4d ago

Go to Apply

Tax Manager, State Income and Franchise - Multistate

Deloitte • Dayton, OH • 4d ago

Finance, Accounting & Banking

Are you a strategic and creative Multistate Tax professional who likes solving complex state tax issues? Are you ready to make a greater impact on organizations by combining tax consulting solutions and innovative techno...

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.