Adjudicator, Provider Medical Claims (Inbound Calls)

Job Description:

Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions.

Provides support for provider claims adjudication activities including responding to providers to address claim issues, and researching, investigating and ensuring appropriate resolution of claims. 

Essential Job Duties:

• Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas/provider billing to facilitate resolution.  

• Collaborates with the member enrollment, provider information management, benefits configuration and claims processing teams to appropriately address provider claim issues. 

• Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions.

• Assists in reviews of state and federal complaints related to claims. 

• Collaborates with other internal departments to determine appropriate resolution of claims issues. 

• Research claims tracers, adjustments, and resubmissions of claims.

• Adjudicates or readjudicates high volumes of claims in a timely manner.

• Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership.

• Meets claims department quality and production standards.

• Supports claims department initiatives to improve overall claim's function efficiency.

• Completes basic claims projects as assigned. 

Required Qualifications:

• 2 years of experience in a clerical role in a claim, and/or customer service setting, including experience in provider claims investigation/research/resolution/reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience.

• Research and data analysis skills.

• Organizational skills and attention to detail.

•Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.

• Customer service experience.  

• Effective verbal and written communication skills.

• Microsoft Office suite and applicable software programs proficiency.

Knowledgeable In Systems Utilized

• Salesforce


• QNXT


• Pega


• Claim Shark


• Cotiviti

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V