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Lead, Provider Inquiry R&R - Claims Disputes

Long Beach, California Job ID 1902984
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Job Description

Job Summary
Molina Health Plan Operations jobs are responsible for the development and administration of our State health plan's operational departments, programs and services, in alignment with Molina Healthcare's overall mission, core values, and strategic plan and in compliance with all relevant federal, state and local regulations.

Provider Inquiry/Services staff are responsible for the submission, research, and resolution of provider inquiries and/or disputes. They respond with the answer to all incoming inquiries and coordinate with other Molina departments as needed to resolve the issue, as well as to correct the underlying cause, ensuring that resolutions are timely and in compliance with all regulatory requirements.

• Serves as team lead for a small group of employees responsible for the submission, research, and resolution of provider inquiries and/or disputes for the Plan. Assures that the workload is evenly distributed, done in a timely manner and that daily goals are met.
• Assists with developing and updating training materials and departmental workflows; trains new employees and provides on-going training as needed. Also may assist with training new External Provider Services staff members within the Provider Services area.
• Assists in claim, eligibility or other questions with assigned providers; provides support to the Director in responding to the more complex provider inquiries; collaborates with other departments as needed to provide timely resolution.


Job Qualifications

Required Education
High School diploma or GED equivalent
Required Experience
• 3 - 5 years customer service, provider service, or claims experience in a managed care setting. Medical office experience may substitute.
• Experience in reviewing different types of medical claims, such as, HCFA 1500, Outpatient/Inpatient UB92, Universal Claims, Stop Loss, Surgery, Anesthesia, high dollar complicated claims, COB or DRG/RCC pricing.

• Candidates with prior experience as Claims Examiners or Claims Adjusters are highly desirable.
Required License, Certification, Association
Preferred Education
Associate's Degree in Business and/or completion of a vocational program in Managed Care or some other health care aspect providing a certificate at completion.
Preferred Experience
3+ years provider claims experience; prior training experience.
Preferred License, Certification, Association

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.


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