Medical Claims Examiner

 
Position: Medical Claims Examiner

Location: US-TX-Houston

Talent Area: Administrative/Clerical

Shift: 8a - 5p

About Texas Children's Hospital

Texas Children’s Health Plan   The Texas Children’s Hospital system is the largest pediatric integrated care system and is an industry leader in pediatric population health.    Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children and pregnant women.   We are an Integrated Community System providing holistic care that empowers families to live healthier lives.     Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.  Currently, the Health Plan serves more than 450,000 members across three state territories (Harris, Jefferson, North East), who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals.    To join our community of 13,000 dedicated team members, visit www.texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at www.infinitepassion.org

Summary:

We are searching for a Medical Claims Examiner -- someone who works well in a fast-paced setting. 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 :

  • Thoroughly reviews, investigates, and adjudicates claims daily, working oldest to newest claim in 30 days or less, and 98% of the time 
  • Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days 
  • The claims should be adjudicated with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports 
  • The claims should be adjudicated with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review 
  • The claims that are manually adjudicated must have notes entered as reviewed by weekly audits, check run, returned claims, management review 98% of the time 
  • Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication 


Qualifications:

  • Being fully vaccinated against COVID-19 is required for all employees unless approved for a medical or religious exemption 
  • High school diploma or GED required 
  • 1 year claims examination experience required 
  • Medical claims examiner experience highly preferred


Apply Now
Current Texas Children’s employees – Please click here to login.
Create Profile or Log In Search Careers