Claims Adjustment Specialist - Kelsey Seybold Clinic - Pearland

Improve the lives of others while Caring. Connecting. Growing together.

Job Description
- Claims Adjustment Specialist
- Kelsey Seybold Clinic
- Pearland (2386448)

Claims Adjustment Specialist
- Kelsey Seybold Clinic
- Pearland - 2386448

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties.

Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.

If you are located in Houston, Texas and have the ability to go to office for meetings / etc., you will have the flexibility to work remotely
* as you take on some tough challenges.

• 45%
  Claims Review & Adjustment:
  • Review claims requiring correction due to processing errors, updated documentation, or system changes
  • Analyze claim history, benefit plans, and prior adjudication to determine appropriate adjustments
  • Perform claim corrections, reversals, and reprocessing in accordance with internal policies and regulatory guidelines
  • Validate accurate payment or denial outcomes following adjustments
• 25%
  Investigation & Resolution:
  • Investigate discrepancies, missing information, or inconsistencies impacting claim outcomes
  • Ensure all actions are clearly documented within the claims system
  • Provide clear, accurate explanations regarding adjustment decisions when required
  • Investigate Data Mining results for potential recovery adjustments
• 15%
  
  Cross-Functional Collaboration:
  • Partner with Claims Processing, Quality Assurance, Training, Escalations, Customer Service, and Appeals teams to resolve issues
  • Support escalated or complex claim scenarios requiring coordination across departments
• 10% Quality & Process Improvement:
  • Identify trends, root causes, and recurring issues contributing to preventable errors
  • Provide feedback and recommendations to improve first-pass claim accuracy and operational efficiency
• 5% Other:
  • Participate in department initiatives and special projects as assigned by leadership
  • Provide subject matter expertise for training, process improvements, and system enhancements
  • Support cross-functional collaboration with Claims, Regulatory, Quality, and Audit teams to achieve departmental goals

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

• High School Diploma or GED
• 2+ years of claims adjudication experience in an HMO, PPO, or TPA environment
• Working knowledge of claim adjudication workflows and benefit interpretation
• Proficiency with Microsoft Office Suite (Excel, Word, Outlook) and spreadsheet tracking
• Proven ability to interpret claim data, supporting documentation, and payer requirements
• Proven ability to work independently while managing multiple priorities
• Demonstrated solid attention to detail with the ability to ensure accuracy and completeness of work
• Demonstrated solid documentation and organizational skills
• Demonstrated professionalism, accountability, and compliance mindset

• Experience specifically in claims adjustments, retro-processing, or complex claim review
• Experience with claims systems such as EPIC, Centricity, or similar platforms
• Experience participating in audit readiness, QA reviews, or error-prevention…