Health Plan Claims Finance Specialist

Overview

In the Claims Finance Specialist position for Sendero Health Plan, a Health Maintenance Organization (HMO), and other Health Plans based in Texas, you will oversee the efficient and accurate processing of refunds, voids, and claim payments.

Essential Functions

• Claims Payment Oversight:
  Responsible for running check payments and coordinating with banks as well as internal finance or external client to ensure all payments are tracked.
• Claim Voids:
  Process outstanding check voids and reissue payments to ensure all payments are made.
• Claim Refunds:
  Apply provider refunds to claims ensuring proper documentation and tracking.
• Claim Recoupments:
  Recoup claims as needed, monitor recoupments, and ensure timely processing.
• Manage Interest and Penalty payments:
  Ensure penalty payments are calculated and paid in a timely manner and identify causes for penalty payments.
• Audit and maintain thorough accounting of all provider and member payments within the VBA database.
• Support Claims Team:
  Support Claims Department on projects and other items as required.

Knowledge,

Skills and Abilities

• Strong understanding of healthcare claims processing principles, coding systems, and reimbursement methodologies.
• Proficiency in utilizing claims processing software and systems (VBA preferrable).
• Excellent communication, and interpersonal skills, with the ability to work independently.
• Thorough knowledge of healthcare regulatory compliance requirements, including HIPAA, CMS guidelines, and Texas regulations.
• Demonstrated ability to effectively manage multiple priorities in a fast-paced environment while maintaining attention to detail and accuracy.

Minimum Education:

High School Diploma or equivalent (higher degree accepted)

Minimum Experience:

7 years of experience in health plans claim finance, preferably within an HMO or managed care environment.

7 years of experience in health plans claim adjudication, preferably within an HMO or managed care environment.