Sr., Claims Examiner - PCHP

Overview

Location:

Mockingbird Towers 4th FLR

The Senior Claims Examiner is responsible for providing claims support by reviewing, analyzing, and researching complex health care claims to identify discrepancies, verify pricing, confirm prior authorizations, and process claims for payment. Remote/hybrid role.

Education

• High school diploma or equivalent required

Experience

• Two (2) years of experience in healthcare claims adjudication required.
• Three (3) years of experience in healthcare claims adjudication in the QNXT platform preferred.
• Experience with managed care organizations (MCOs) or health plans preferred.
• Experience working with Texas Medicaid claims and regulatory requirements is preferred.

Skills Or Special Abilities

• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.
• Knowledge of Networ
  
  X Pricer for claims pricing and reimbursement is a plus.
• 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.
• 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.
• 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.

• Accurately review, process, and adjudicate medical claims in compliance with Texas Medicaid policies and PCHP guidelines.
• Utilize QNXT (preferred) to enter, adjust, and validate claims data. Ensure correct application of benefit plans, provider contracts, pricing schedules, and service contracts to claims adjudication.
• Analyze claims to confirm the appropriate use of CPT, ICD, HCPCS, and revenue codes against billed charges.
• Manually adjust pended or escalated claims to resolve complex issues related to provider disputes, coordination of benefits (COB), and payment errors.
• 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.
• Participate in testing and training for system updates, including enhancements in QNXT and other claims processing platforms.
• Quality
• 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.
• Identify opportunities for workflow improvements to enhance accuracy, efficiency, and timeliness of claims adjudication.
• Ensures high accuracy in claims adjudication to maintain compliance with policies and regulations.
• Navigates various systems to ensure accurate and timely processing of claims, ultimately improving health outcomes for members.

• Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.
• Stay up to date with Texas Medicaid regulations, CMS guidelines, and PCHP policies to ensure accurate claims processing.
• Assist in updating procedures and policies based on…