Claims Examiner

Job Description

We are looking for a Claims Examiner, someone who’s ready to grow with our company. In this position, you will process and adjudicate claims received for reimbursement to Providers based on extensive review, research, and a detailed format of claim processing procedures.

We are looking for a Claims Examiner, someone who’s ready to grow with our company. In this position, you will process and adjudicate claims received for reimbursement to Providers based on extensive review, research, and a detailed format of claim processing procedures.

• Adjudicate 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.
• Examiners should process at least 14 claims per hour, or 98 claims per day.
• Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days.
• Macess requests are processed within 30 days of receipt, with a 98% accuracy, to ensure timely resolution of claims, in adherence with HHSC regulatory requirements.
• 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.
• 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.
• Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication.
• Complete special projects as requested.

• Required H.S. Diploma or GED
• Required 1 year claims examination experience

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 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

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.