JOB DESCRIPTION Job Summary
Provides support for claims examination activities including evaluation of
adjudication of claims to identify incorrect coding, abuse and fraudulent
billing practices, waste, overpayments, and processing errors.
Essential Job Duties
• Evaluates the adjudication of claims using standard principles, and
state-specific regulations to identify incorrect coding, abuse and fraudulent
billing practices, waste, overpayments, and claims processing errors.
• Manages a caseload of claims - procures all medical records and statements
that support the claim.
• Makes recommendations for further investigation and/or resolution of claims.
• Reduces defects through proactive identification of error issues as it
relates to pre-payment of claims through adjudication/trend identification, and
recommends solutions to resolve issues.
• Meets claims department quality and production standards.
• Supports claims department initiatives to improve overall claims function
efficiency.
• Completes basic claims projects as assigned.
Required Qualifications
• At least 1 year of experience in a clerical role in a claims, and/or customer
service setting - preferably in managed care, or equivalent combination of
relevant education and experience.
• Data entry and research 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.
Preferred Qualifications
• Health care claims/billing experience.
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