Medical Claims Examiner

Position: Medical Claims Examiner

Job ID: 401512

Location: US-TX-Houston

Department: Claims - Examination

Talent Area: Administrative Support

Full/Part Time: Full time

Regular/Temporary: Regular

Shift: 7am - 5pm

About Texas Children's Hospital

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.

To join our community of 14,000+ dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at

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.


We are searching for a Medical Claims Examiner - someone who works well in a fast-paced managed care setting. In this position, you’ll process and adjudicate claims received for reimbursement to Providers based on extensive review, research and a detailed format of claim processing procedures. Additionally, you’ll make routine decisions including claims adjudication within the appropriate levels of authority.

Think you’ve got what it takes?


  • Adjudicate Medical claims received into processing system
  • Thoroughly reviews, investigates and adjudicates claims daily, working oldest to newest claim in 30 days or less, and 98% of the time
  • The claims are processed accurately as defined by standard guidelines
  • The claims should be adjudicated with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports
  • Special projects as requested
  • Examiner should process a minimum of 14 claims per hour, or a minimum of 98 claims per day
  • The claims should be adjudicated with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review
  • Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days
  • 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
  • Access requests are processed within 30 days of receipt, with a 98% accuracy, to ensure timely resolution of claims, in adherence with HHSC regulatory requirements


  • Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s, unless approved for a medical or religious exemption.
  • High school diploma or GED
  • One year Medical claims examination experience

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