Senior Claims Examiner - Health Plan

We are searching for a Senior Claims Examiner — someone who works well in a fast-paced setting. In this position, you will process and adjudicate claims received for reimbursement to all Providers based on extensive review, research and a detailed format of claim processing procedures.

Think you’ve got what it takes?
 

Qualifications:

•   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 Required
•   2 Years Claims Processing Experience Required
 

Responsibilities:

•   Thoroughly reviews, investigates and adjudicates claims daily, working oldest to newest claim in 30 days or less, 98% of the time
•   Process a minimum of 14 claims per hour, or a minimum of 98 claims per day
•   Conduct review and investigation of pending 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
•   Proactively identifies system or end-user issues and reports them promptly to initiate quick resolution of issue
•   Participate in system testing and reviews for upgrades/implementation
•   Prepare and run various reports for Claims Administration to expedite aging claims resolution
•   Responsible for processing and completing the Pay-to Paid, and Claims Aging Report to ensure claims are processed within 30 days of receipt, in adherence with HHSC regulatory requirements
 

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