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SalaryJob Description
Job Summary
The Sr. Provider Claims Adjudicator is responsible for responding to providers regarding complex issues with claims, coordinating, investigates and confirms the appropriate resolution of claims issues. This role will require extensive experience to provide counsel to Provider Adjudicators and lead the work related to research and analytical work related to adjusting complex claims. Requires knowledge of multiple operational areas and systems.
Knowledge/Skills/Abilities
Investigates and facilitates the resolution of complex claims issues, including incorrectly paid claims, by working with multiple operational areas and provider billings and analyzing the systems.
This senior level role is involved in complicated enrollment, provider information management, benefits configuration and/or Claims processing.
Responds to incoming calls from providers regarding elaborate claims inquiries and provides outstanding customer service; documents calls and interactions.
Identifies the interdependencies of the resolution of claims errors on other activities within operations.
Lead in the reviews of state or federal complaints related to claims.
Facilitates the efforts of several internal departments to determine appropriate resolution of issues within strict timelines.
Interacts with network providers and health plans regularly to manage customer expectations, communicate risks and status updates, and ensure issues are fully resolved.
Performs claims and trend analysis, ensures supporting documentation is accurate and obtains necessary approvals to close out claim’s issues.
Leads overall performance accountability (attendance, communication, flexibility, adaptability, interpersonal skills, teamwork and cooperation).
Researches tracers, adjustments, and re-submissions of more complex claims.
Adjudicates or re-adjudicates high volume of claims in a timely manner to ensure compliance to departmental turn-around time and quality standards.
Leads the management of defect reduction by identifying and communicating error issues and potential solutions to management.
Handles special projects as assigned and required by changes in claims payment policies or contracting methodologies.
I nbound call center experience and advanced level claims (Medical)
Knowledgeable in systems utilized:
QNXT
Pega
Verint
Kronos
Microsoft Teams
Video Conferencing
Others as required by line of business or state
Job Function
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.
Job Qualifications
REQUIRED EDUCATION:
Associate’s Degree or equivalent combination of education and experience
REQUIRED EXPERIENCE:
4-5 years customer service, claims, provider experience. Leadership skills, process improvement, innovation and investigation/research. Outcome focused and knowledge of multiple systems.
2+ 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:
5-7 years
PHYSICAL DEMANDS:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in a home and 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.
Pay Range: $16.23 - $35.17 / HOURLY
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
