Job Description

Leads and supervises team responsible for claims activities including administering claims payments, maintaining claim records, and providing counsel to Providers regarding coverage amount and benefit interpretation. Also monitors and controls backlog and workflow of claims and ensures that claims are settled in a timely fashion and in accordance with cost-control standards.

Essential Job Duties

• Coordinates workflow and staffing of day-to-day claims activities and assigns and monitors work of staff in order to adhere to productivity and quality standards.

• Hires, onboards, trains, supervises, and develops claims team, and demonstrates accountability for team performance.

• Proactively plans for daily claims priorities, and responds to new priorities and process improvement opportunities assigned by leadership.

• Ensures execution of claim handling strategies including appropriate determination of coverage, processing guidelines and metrics.

• Reviews and analyzes claim reports to identify and address trends; recommends strategies to correct adverse trends.

• Effectively manages claims escalations within the department by ensuring appropriate accountability, sense of urgency, communication and follow-through to closure.

• Reviews and documents recommendations for claim disposition including evaluation, negotiation and settlement of claims in excess of staff authority levels.

• Compiles and submits daily, weekly and monthly departmental claims reports to leadership.

• In collaboration with senior claims leadership, develops claims department initiatives to improve overall efficiency.

• Completes claims projects as assigned.

Required Qualifications

• At least 5 years of medical claims processing experience, or equivalent combination of relevant education and experience.

• Thorough knowledge of processing outpatient and inpatient facility claims for Medicare, Medicaid, and Marketplace plans.

• Research, analysis, data entry, and auditing skills.

• Organizational skills and attention to detail.

• Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.

• Ability to work cross-collaboratively in a highly matrixed environment.

• Strong customer service experience.

• Effective verbal and written communication skills.

• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Management/leadership experience.

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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