Claims representative Jobs in Portland, OR

Job Summary

Provides analyst support for claims research activities including reviewing and researching claims to ensure regulatory requirements are appropriately applied, identifying root-cause of processing errors through research and analysis, coordinating and engaging with appropriate departments, developing and tracking remediation plans, and monitoring claims reprocessing through resolution.

Essential Job Duties

• Serves as claims subject matter expert - using analytical skills to conduct research and analysis to address issues, requests, and support high-priority claims inquiries and projects.
• Interprets and presents in-depth analysis of claims research findings and results to leadership and respective operations teams.
• Manages and leads major claims projects of considerable complexity and volume that may be initiated internally, or through provider inquiries / complaints, or legal requests.
• Assists with reducing rework by identifying and remediating claims processing issues.
• Locates and interprets claims-related regulatory and contractual requirements.
• Tailors existing reports and / or available data to meet the needs of claims projects.
• Evaluates claims using standard principles and applicable state-specific regulations to identify claims processing errors.
• Applies claims processing and technical knowledge to appropriately define a path for short / long-term systematic or operational fixes.
• Seeks to improve overall claims performance, and ensure claims are processed accurately and timely.
• Identifies claims requiring reprocessing or readjudication in a timely manner to ensure compliance.
• Works collaboratively with internal / external stakeholders to define claims requirements.
• Recommends updates to claims standard operating procedures (SOPs) and job aids to increase the quality and efficiency of claims processing.
• Fields claims questions from the operations team.
• Interprets, communicates, and presents clear in-depth analysis of claims research results, root-cause analysis, remediation plans and fixes, overall progress, and status of impacted claims.
• Appropriately conveys claims-related information and tailors communication based on targeted audiences.
• Provides sufficient claims information to internal operations teams that communicate externally with providers and / or members.
• Collaborates with other functional teams on claims-related projects, and completes tasks within designated / accelerated timelines to minimize provider / member impacts and maintain compliance.
• Supports claims department initiatives to improve overall claims function efficiency.

Required Qualifications

Preferred Qualifications

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 - $46.42 / HOURLY