Specialist, Claims

Job Description

Job Summary

Thorough knowledge of processing professional, outpatient facility, and inpatient facility claims for Medicare, Medicaid, and Marketplace plans. Assists Molina departments with reviewing and conducting analysis of claims to ensure regulatory requirements are appropriately applied. Clearly documents claims research results and root cause of processing errors. Recommends remediation plan and assists with monitoring of claims reprocessing. Supports and contributes towards the summary and presentation of findings. Responsible for ensuring the claims research is completed accurately by the established timelines.

Job Duties

• Uses claims knowledge to conducts research and analysis for assigned claims projects
• Communicates clear in-depth analysis of claims research results and recommended remediations
• Engages appropriate departments to deliver accurate analysis
• Apply regulatory and contractual requirements and communicate if system and/or Claims documentation requires updates
• Requests appropriate claims data to minimize manual claims research
• Research claims using standard principles and applicable state specific policies and regulations
• Helps to improve overall claims performance to ensure claims are processed accurately and timely
• Identifies claims requiring reprocessing or re-adjudication in a timely manner to ensure compliance
• Able to work in a project team setting while also able to complete tasks individually within the provided timeline or as needed, accelerated timeline to minimize provider/member impacts and/or maintain compliance
• Manages work assignments to ensure accurate completion by the established timelines
  
  

Job Qualifications

REQUIRED EDUCATION:

High School Degree or GED

Required Experience/Knowledge, Skills & Abilities

• 3-5 years medical claims processing experience
• Demonstrates familiarity in a variety of concepts, practices, and procedures applicable to job-related subject areas.
• Ability to work with Excel
  
  

Preferred Education

Associate’s Degree or equivalent combination of education and experience

Preferred Experience

• 1-3 years claims analysis
• 5-7 years medical claims processing experience
• Proficient in Excel
  
  

Physical Demands

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: $16.9 - $31.97 / HOURLY

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