[Hiring] Lead Adjudicator @Molina Healthcare

Role Description

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.

• 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.

Qualifications

• Associate’s Degree or equivalent combination of education and experience.
• Minimum 3 years as a Provider Claims Adjudicator.
• Previous claims adjusting experience as well as customer services, problem solving, critical thinking skills and research and resolution skills.
• Strong attention to detail.
• Strong analytical skills.
• Bachelor’s Degree or equivalent combination of education and experience (preferred).
• 6+ years previous claims adjusting and customer services experience (preferred).

Requirements

• 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.

Benefits

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