Adjudicator, Provider Claims

JOB DESCRIPTION Job Summary Provides 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 u2022 Provides support for resolution of provider claims issues, including claims paid incorrectly; analyzes systems and collaborates with respective operational areas/provider billing to facilitate resolution. u2022 Collaborates with the member enrollment, provider information management, benefits configuration and claims processing teams to appropriately address provider claim issues. u2022 Responds to incoming calls from providers regarding claims inquiries - provides excellent customer service, support and issue resolution; documents all calls and interactions. u2022 Assists in reviews of state and federal complaints related to claims. u2022 Collaborates with other internal departments to determine appropriate resolution of claims issues. u2022 Researches claims tracers, adjustments, and resubmissions of claims. u2022 Adjudicates or readjudicates high volumes of claims in a timely manner. u2022 Manages defect reduction by identifying and communicating claims error issues and potential solutions to leadership. u2022 Meets claims department quality and production standards. u2022 Supports claims department initiatives to improve overall claims function efficiency. u2022 Completes basic claims projects as assigned. Required Qualifications u2022 At least 2 years of experience in a clerical role in a claims, and/or customer service setting, including experience in provider claims investigation/research/resolution/reimbursement methodology analysis within a managed care organization, or equivalent combination of relevant education and experience. u2022 Research and data analysis skills. u2022 Organizational skills and attention to detail. u2022Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines. u2022 Customer service experience. u2022 Effective verbal and written communication skills. u2022 Microsoft Office suite and applicable software programs proficiency. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $21.16 - $38.37 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-12-05