Lead Adjudicator, Provider Claims

Job Description

Job Summary

Responsible for work load assignment to the provider Claims adjudicators and senior provider claims adjudicators. Train and coach new employees.  Provide clear and concise results on the provider claims model across all states. Monitors and controls workflow. Provides support to leadership supporting the team on researching and resolving claims issues and addressing employees escalations related to complex claims issues.

Shift: 11:30 AM- 8:00 PM EST, Rotating holidays

Job Duties

• Coordinates work flow and staffing of day-to-day activities as well as assigns and monitors work of staff in order to adhere to productivity and quality standards.
• Effectively manages escalations within the department by ensuring appropriate accountability, sense of urgency, communication and follow through to closure.
• Perform daily troubleshooting procedures to support Provider Claims functions as needed.
• Participates in or leads quality improvement efforts to improve processes and/or policies.
• Serves as subject matter expert and provide feedback to team and provide training as needed.
• Reviews deficiencies and makes recommendations on increasing efficiencies and provider satisfaction.
• Supports leading the team to have exemplary customer service and ensure the team is meeting metrics and compliance measures.
• Partners with stakeholders and leaders in other divisions help coordinate problem solving in an effective and timely manner.
• Provides technical expertise to co-workers and handles complex calls.
• Assists supervisor with development with staff. 
• Recognizes trends and patterns in call and claims types and engages leadership with suggested solutions.
• Achieves individual performance goals as it relates to claims adjudication.
• Assists with training needs of employees as needed.
• Demonstrates personal responsibility and accountability by meeting attendance and schedule adherence expectations.
• Other duties as assigned.
• Occasionally handle escalated or complex customer issues and provide timely and effective resolution

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

Experience in QNXT, Salesforce, Claims Viewer, Claim Shark, PEGA, Cotiviti, ECHO, CEMs Edifecs

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.

Pay Range: $19.84/hr - $38.69/hr*

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Pay Range: $21.16 - $46.42 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.