Lead Adjudicator, Provider Claims

Provides lead level 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

• Coordinates workflow and staffing of day-to-day claims adjudication activities, and assigns and monitors work of staff to ensure adherence to productivity and quality standards.

• Manages escalations within the claims department by ensuring appropriate accountability, sense of urgency, communication and follow-through to closure.

• Performs daily claims troubleshooting procedures to support provider claims function as needed.

• Participates in or leads quality improvement efforts to improve claims processes and/or policies.

• Serves as provider claims subject matter expert; provides feedback to team and facilitates training as needed. 

• Reviews claims deficiencies and makes recommendations to increase efficiencies and provider satisfaction.

• Sets standard with team for exemplary customer service delivery and ensures the team is meeting established claims metrics and compliance measures.

• Partners with stakeholders and leaders in other functions to coordinate provider claims-related problem-solving in an effective and timely manner.

• Provides technical claims expertise to peers and handles complex provider calls.

• Assists with training needs of claims department staff.

• Assists leadership with claims staff development. 

• Recognizes trends and patterns in call and claims types and engages leadership with suggested solutions. 

• Meets department quality and production standards.

• Supports all claims department initiatives to improve overall efficiency.

• Completes claims projects as assigned.

 

Required Qualifications

• At least 4 years of experience in claims, including provider claims investigation/research/resolution/reimbursement methodology analysis experience within a managed care organization, and 3 years experience as a claims adjudicator, or equivalent combination of relevant education and experience.
• Experience with claims payments, multiple state billing guidelines and claims processing policies and procedures.
• Research, analysis, data entry, and auditing 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.

 

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

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