Adjudicator, Provider Claims

Provider Claims Adjudicator

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

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.

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.

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.