JOB DESCRIPTION Job Summary
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.
Job Qualifications
REQUIRED EDUCATION:
Associate’s Degree or equivalent combination of education and experience
REQUIRED EXPERIENCE/KNOWLEDGE, SKILLS & ABILITIES:
Minimum 3 years as a Provider Claims Adjudicator
Previous claims adjusting experience as well and customer services, problem solving, critical thinking skills and research and resolution skills.
Strong attention to detail
Strong analytical skills
PREFERRED EDUCATION:
Bachelor’s Degree or equivalent combination of education and experience
PREFERRED EXPERIENCE:
6+ years previous claims adjusting and customer services experience
PHYSICAL DEMANDS:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an 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.
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
offers a competitive benefits and compensation package. is an Equal Opportunity Employer (EOE) M/F/D/V
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