Claims/Benefits Specialist

Job Duties & Responsibilities

• Process Specialists Adjustments, Replacements, Refunds, and Appeals Queues, Group queues content at 98% average, within 30 days of receipt
• Review and process pended claims, within 5 days of initial review
• Respond to internal inquiries within 48 hours of receipt
• Review, investigate and provide accurate and efficient follow-up
• Ensure Special Projects are completed accurately, in a timely and efficient manner
• Participates in system testing and reviews for upgrades/implementation
• Identify and communicate to team, leadership, and other departments (if applicable), trends related to appeals processing, not yet addressed in a desk level procedure or identified by another team member
• Collaborate with Provider Relations team to educate providers regarding trends identified in appeals process
• Analyze potential system configuration setup issues when trending appeals to determine if modifications must be made to increase the automation of the adjudication flow
• Investigate and research Texas Medicaid regulatory requirements for various payment methodologies for hospitals, physicians, home health agencies, CORFs, etc., to apply to various claim scenarios where system cannot be automated
• Utilize expertise with federal NCCI edits, MUE edits, etc., to determine if providers are billing inappropriately or fraudulently
• Refer potential fraud activity to FWA unit for further investigation
• Evaluate the appropriateness of code bundling, un-bundling, and addition of modifiers by provider to determine if higher level of payment is warranted or if provider is upcoding
• Refers trends of inappropriate activity for further data analytics for potential fraud
• Process and coordinate claims identified by the Fraud, Waste & Abuse (FWA) department for retraction and/or reprocessing
• Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt

About the Role

Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children’s Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.

Requirements

• HS Diploma Or GED Required
• 3 Years Claims Processing Experience Required
• A Bachelor’s degree may substitute for the required experience

Skills

• Utilize expertise with federal NCCI edits, MUE edits, etc., to determine if providers are billing inappropriately or fraudulently
• Evaluate the appropriateness of code bundling, un-bundling, and addition of modifiers by provider to determine if higher level of payment is warranted or if provider is upcoding
• Collaborate with Provider Relations team to educate providers regarding trends identified in appeals process
• Process and coordinate claims identified by the Fraud, Waste & Abuse (FWA) department for retraction and/or reprocessing
• Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt

Qualifications

• HS Diploma Or GED Required
• 3 Years Claims Processing Experience Required

Benefits

Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.