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Senior Claims Examiner - Health Plan

Houston, TX, US
    Position: Senior Claims Examiner - Health Plan
    Talent Area: Clerical
    Full/Part Time: Full time
    Location: Houston, TX, US
    Regular/Temporary: Regular
    Department: Claims - Examination
    Shift: 8a-5p
    Job ID: 405510

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?


•   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


•   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

About Texas Children’s

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.

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