Medical Claims Specialist

Position: Medical Claims Specialist

Job ID: 402685

Location: US-TX-Houston

Department: Claims - Examination

Talent Area: Administrative Support

Full/Part Time: Full time

Regular/Temporary: Regular

Shift: 8a-5p

About Texas Children's Hospital

Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years.

Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, a second community hospital opening in 2017. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.

To join our community of 13,000 dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at


We are looking for a Claims and Benefits Specialist, someone who’s ready to grow with our company. In this position, investigate and accurately process claim appeals within the regulatory requirements mandated by the State of Texas. 

Think you’ve got what it takes? 

Job Duties & Responsibilities 

  • Claims Processing 
    • Process Specialists Adjustments, Replacements, Refunds, and Appeals Queues, at 98% average, within 30 days of receipt. (Specialists must process a minimum of 6 claims per hour, per day, annual average). 
    • Process group queues content at 98% average, within 30 days of receipt. 
    • Review and process pended claims, within 5 days of initial review.  
  • Internal Customer Requests and Special Projects 
    • 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.  
  • Trends Identification and Analysis 
    • 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. 
    • Collaborates with Provider Relations team to educate providers regarding trends identified in appeals process. 
    • Analyzes potential system configuration setup issues when trending appeals to determine if modifications must be made to increase the automation of the adjudication flow. 
    • Investigates and researches 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. 
    • Utilizes expertise with federal NCCI edits, MUE edits, etc., to determine if providers are billing inappropriately or fraudulently. Refers potential fraud activity to FWA unit for further investigation. 
    • Evaluates 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. 
  • External Appeals Processing 
    • Process refunds/retractions identified by TCHP contracted vendors or other external or internal source, within 30 days of notification. 
    • Process and coordinate claims identified by the Fraud, Waste & Abuse (FWA) department for retraction and/or reprocessing. Provides reporting on reduction in advances made to providers on FWA watch. 
    • Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt. 

Skills & 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.  
  • MCO experience and Texas Medicaid experience strongly preferred 
  • H.S. Diploma or GED required 
  • 3 Years of claims processing experience required

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