Claims Examiner
About the role
We are looking for a Claims Examiner who’s ready to grow with our company. In this position, you will process and adjudicate claims received for reimbursement to Providers based on extensive review, research, and a detailed format of claim processing procedures.
Responsibilities
- Adjudicate claims received into processing system, working oldest to newest claim in 30 days or less, and 98% of the time.
- Process at least 14 claims per hour, or 98 claims per day.
- Conduct review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days.
- Process Macess requests within 30 days of receipt, with a 98% accuracy, to ensure timely resolution of claims in adherence with HHSC regulatory requirements.
- Adjudicate claims with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports.
- Adjudicate claims with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review.
- Ensure manually adjudicated claims have notes entered 98% of the time, as reviewed by weekly audits, check run, returned claims, and management review.
- Enter clear, concise documentation/notes for each claim reviewed to provide a historical reference of how the claim was processed at the time of adjudication.
- Complete special projects as requested.
Requirements
- High School Diploma or GED.
- 1 year of claims examination experience.
About Us
Founded in 1996, 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.