Molina Medicaid Solutions - DHHR

Bridging the Rivers ofChange TogetherWest Virginia MMIS Re-ProcurementSolicitation: MED13006ROLE RESPONSIBILITIES SKILL SETscanning, keying, mail sorting, documentprinting, and mailing Strong knowledge of medical claimspayment systemsClaimsResolutionSpecialistClaimsSupervisor(Lead)Administers prior authorization activitiesMaintains oversight for the management offinancial activities and state funddisbursementsDevelops and oversees claims processingoperations and all associated manualprocessesDevelops and coordinates changes andenhancements and identifies the impactsthese modifications have on the claimsmoduleManages claims processing staffEstablishes and maintains relationshipswith the StateCommunicates with providers concerningcomplex claims adjudication processesManages the daily operations of the claimdepartment and mailroomMeets with the State regarding policy andproceduresEnsures external claims data vendors meetcontractual obligationsEnsures that all quality standards are metto assure claims processing accuracyDelegates and prioritizes task assignmentsof claims and mailroom staffEvaluates processes for improvementSupports all initiatives in improvingoverall efficiencyProcesses claim forms, adjudicates forallocation of deductibles, co-pays, coinsurancemaximums and providerreimbursementsFollows adjudication policies andprocedures to ensure proper payment ofclaimsResolves pending claims based onMedicaid rules and regulation establishedfor final processingMeets established production requirementsconsistentlyMaintains an accuracy rate of 98 percent orbetterSupervises claims processing staff andmonitors daily operations according toclient policies and proceduresDelegates and prioritizes task assignmentsThorough understanding of CPT/HCPCSand ICD-9 coding procedures andguidelinesKnowledgeable in Microsoft officeproducts such as word and excelExcellent verbal and writtencommunication skillsHigh School diploma or GEDOne to two years general office experiencein a claims environmentKnowledge of Microsoft Office productsGeneral knowledge of personal computerGood verbal and written communicationskillsHigh School Diploma or equivalencyWorking knowledge of mailroomoperationsFive years supervision/lead in a claims14.4-18