Claims Adjudicator - PCHP

Primary Purpose

Parkland Community Health Plans (PCHPs) Claims Adjudicator is responsible for reviewing, adjudicating, and resolving Medicaid healthcare claims within the QNXT system. This role supports efficient claims operations, maintaining high accuracy while meeting production targets and ensuring compliance with TMHP and Medicaid guidelines. This is a Hybrid role with some in-office meetings required.

• High school diploma or equivalent required.

• Two (2) years of experience in healthcare claims adjudication required.

• Expertise in the QNXT platform preferred.

• Experience working with Texas Medicaid claims and Medicaid regulatory requirements is preferred.
• Knowledge of Networ
  
  X Pricer for claims pricing and reimbursement is a plus.

• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.

• Excellent analytical and problem-solving skills.

• Proficient in adjudicating claims using QNXT, including resolution of pended or denied claims.
• Proficient computer and Microsoft Office skills. Ability to learn new software programs.

• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

• Strong understanding of claims adjudication processes, benefit structures, and provider contracts.
• Familiarity with the claim's life cycle, including submission, processing, adjudication, and payment processes.
• Ability to identify and resolve claim discrepancies effectively and efficiently.
• Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Ability to write clearly and succinctly with a high level of attention to detail.

• Review and process healthcare claims within the QNXT system, ensuring compliance with benefit policies, pricing, and regulatory guidelines.
• Adjudicate claims accurately by analyzing supporting documentation, provider contracts, and fee schedules.
• Investigate and resolve pended or denied claims by applying appropriate corrections in QNXT.
• Collaborate with internal teams to identify, address, and resolve systemic claims issues. Meet or exceed established productivity targets for claims adjudication in a high-volume environment.
• Effectively prioritize and manage workload to meet deadlines and organizational objectives.
• Document claim outcomes, adjustments, and resolutions accurately within the QNXT system.
• Provide updates and insights on claims performance metrics to supervisors as needed.

• Integrate health literacy principles into all communication including Members and Providers.
• Support strategies that meet clinical, quality and network improvement goals.
• Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
• For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.
• Ensures high accuracy in claims adjudication to meet quality standards and maintain compliance with policies and regulations.

• Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.
• Ensure all claims are adjudicated in alignment with TMHP guidelines, Medicaid regulations, and internal policies.

• Promotes and supports a culturally welcoming and inclusive work environment.
• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned…