Medical Claims Examiner jobs at Texas Children's Hospital

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024. For more information, visit AmHealthPlans.com. If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application! Benefits and Perks include: * Affordable Medical/Dental/Vision insurance options * Generous paid time-off program and paid holidays for full time staff * TeleMedicine 24/7/365 access to doctors * Optional short- and long-term disability plans * Employee Assistance Plan (EAP) * 401K retirement accounts * Employee Referral Bonus Program ESSENTIAL JOB DUTIES: To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation. * Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials * Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standards * Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment * Work assigned claim projects to completion * Provide a high level of customer service to internal and external customers; achieve quality and productivity goals * Escalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and procedures * Maintain production and quality standards as established by management * Participate in and support ad-hoc audits as needed * Other duties as assigned JOB REQUIREMENTS: * Proficient in processing/auditing claims for Medicare and Medicaid plans * Strong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulations * Current experience with both Institutional and Professional claim payments * Knowledge of automated claims processing systems * Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office. REQUIRED QUALIFICATIONS: * Experience: * Two (2) years' experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system * Two (2) years' experience in managed healthcare environment related to claims processing/audit * Two (2) years' experience with standard coding and reference materials used in a claim setting, such as CPT4, ICD10 and HCPCS * Two (2) years' experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations * Two (2) years' experience processing/auditing claims for Medicare and Medicaid plans * License/Certification(s): * Coding certification preferred EQUAL OPPORTUNITY EMPLOYER Our Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. This employer participates in E-Verify.

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024. For more information, visit AmHealthPlans.com. If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application! Benefits and Perks include: * Affordable Medical/Dental/Vision insurance options * Generous paid time-off program and paid holidays for full time staff * TeleMedicine 24/7/365 access to doctors * Optional short- and long-term disability plans * Employee Assistance Plan (EAP) * 401K retirement accounts * Employee Referral Bonus Program ESSENTIAL JOB DUTIES: To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation. * Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials * Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standards * Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment * Work assigned claim projects to completion * Provide a high level of customer service to internal and external customers; achieve quality and productivity goals * Escalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and procedures * Maintain production and quality standards as established by management * Participate in and support ad-hoc audits as needed * Other duties as assigned JOB REQUIREMENTS: * Proficient in processing/auditing claims for Medicare and Medicaid plans * Strong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulations * Current experience with both Institutional and Professional claim payments * Knowledge of automated claims processing systems * Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office. REQUIRED QUALIFICATIONS: * Experience: * Two (2) years' experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system * Two (2) years' experience in managed healthcare environment related to claims processing/audit * Two (2) years' experience with standard coding and reference materials used in a claim setting, such as CPT4, ICD10 and HCPCS * Two (2) years' experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations * Two (2) years' experience processing/auditing claims for Medicare and Medicaid plans * License/Certification(s): * Coding certification preferred EQUAL OPPORTUNITY EMPLOYER Our Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. This employer participates in E-Verify.

HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service. We are proud to say that for three years, HMA has been chosen as a ‘Washington's Best Workplaces' by our Staff and PSBJ™. Our vision, ‘Proving What's Possible in Healthcare™,' and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results. What we are looking for: We are always searching for unique people to add to our team. We only hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team, are motivated by tackling complex challenges, are courageous enough to share ideas, action-oriented, resilient, and results-driven. What you can expect: You can expect an inclusive, flexible, and fun culture, comprehensive salary, pay transparency, benefits, and time off package with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at: ***************** How YOU will make a Difference: As a Claims Specialist, you'll be at the heart of our mission to deliver exceptional service. Working alongside a dedicated team, you'll ensure the accurate and timely processing of medical, dental, vision, and short-term disability claims that HMA administers for our members. Your role goes beyond handling claims, you'll be a key player in shaping a positive healthcare experience for our members. Every claim you interact with helps someone navigate their healthcare journey with confidence, making your work both meaningful and impactful. What YOU will do: Carefully research discrepancies, process returned checks, issue refunds, and manage stop payments with precision. This ensures financial accuracy and builds trust with both clients and members. Manage high-importance claims and vendor billing with urgency and attention to detail. Review and reply to appeals, inquiries, and other communications related to claims. Work with third-party organizations to secure payments on outstanding balances. Process case management and utilization review negotiated claims Spot potential subrogation claims and escalate them appropriately. Actively contribute to team success by assisting colleagues when workloads peak, sharing knowledge, and fostering a collaborative environment. Requirements High school diploma required 3-5+ years of claims processing experience 2+ years of BCBS claims processing experience Strong interpersonal and communication skills Strong attention to detail, with high degree of accuracy and urgency Ability to take initiative and ownership of assigned tasks, working independently with minimal supervision, yet maintain a team-oriented and collaborative approach to problem solving Previous success in a fast-paced environment Benefits Compensation: The base salary range for this position in the greater Seattle area is $28/hr - $32/hr for a level II and varies dependent on geography, skills, experience, education, and other job or market-related factors. While we are looking for level II, we may consider level III for highly qualified candidates. Disclaimer: The salary, other compensation, and benefits information are accurate as of this posting date. HMA reserves the right to modify this information at any time, subject to applicable law. In addition, HMA provides a generous total rewards package for full-time employees that includes: Seventeen (IC) days paid time off (individual contributors) Eleven paid holidays Two paid personal and one paid volunteer day Company-subsidized medical, dental, vision, and prescription insurance Company-paid disability, life, and AD&D insurances Voluntary insurances HSA and FSA pre-tax programs 401(k)-retirement plan with company match Annual $500 wellness incentive and a $600 wellness reimbursement Remote work and continuing education reimbursements Discount program Parental leave Up to $1,000 annual charitable giving match How we Support your Work, Life, and Wellness Goals At HMA, we believe in recognizing and celebrating the achievements of our dedicated staff. We offer flexibility to work schedules that support people in all time zones across the US, ensuring a healthy work-life balance. Employees have the option to work remotely or enjoy the amenities of our renovated office located just outside Seattle with free parking, gym, and a multitude of refreshments. Our performance management program is designed to elevate career growth opportunities, fostering a collaborative work culture where every team member can thrive. We also prioritize having fun together by hosting in person events throughout the year including an annual all hands, summer picnic, trivia night, and a holiday party. We hire people from across the US (excluding the state of Hawaii and the cities of Los Angeles and San Francisco.) HMA requires a background screen prior to employment. Protected Health Information (PHI) Access Healthcare Management Administrators (HMA); employees may encounter protected health information (PHI) in the regular course of their work. All PHI shall be used and disclosed on a need-to-know-basis and according to HMA's standard policies and procedures. HMA is an Equal Opportunity Employer. For more information about HMA, visit: *****************

HMA is the premier third-party health plan administrator across the PNW and beyond. We relentlessly deliver on our promise to provide medium to large-size employers with customized health plans. We offer various high-quality, affordable healthcare plan options supported with best-in-class customer service. We are proud to say that for three years, HMA has been chosen as a ‘Washington's Best Workplaces' by our Staff and PSBJ™. Our vision, ‘Proving What's Possible in Healthcare™,' and our values, People First!, Be Extraordinary, Work Courageously, Own It, and Win Together, shape our culture, influence our decisions, and drive our results. What we are looking for: We are always searching for unique people to add to our team. We only hire people that care deeply about others, thrive in evolving environments, gain satisfaction from being part of a team, are motivated by tackling complex challenges, are courageous enough to share ideas, action-oriented, resilient, and results-driven. What you can expect: You can expect an inclusive, flexible, and fun culture, comprehensive salary, pay transparency, benefits, and time off package with plenty of personal development and growth opportunities. If you are looking for meaningful work, a clear purpose, high standards, work/life balance, and the ability to contribute to something important, find out more about us at: ***************** How YOU will make a Difference: As a Claims Specialist, you'll be at the heart of our mission to deliver exceptional service. Working alongside a dedicated team, you'll ensure the accurate and timely processing of medical, dental, vision, and short-term disability claims that HMA administers for our members. Your role goes beyond handling claims, you'll be a key player in shaping a positive healthcare experience for our members. Every claim you interact with helps someone navigate their healthcare journey with confidence, making your work both meaningful and impactful. What YOU will do: Research and process ITS claim adjustments, returned checks, refunds and stop payment in an accurate and timely manner Communicate with local Blue plans utilizing real time chat Process priority claims and general inquiries Respond to appeals and correspondence regarding claims functions Support team members and be open to providing assistance when and where neede Become a SME regarding BCBS network Requirements High school diploma required 3-5+ years of claims processing experience 2+ years of BCBS claims processing experience required Strong interpersonal and communication skills Strong attention to detail, with high degree of accuracy and urgency Ability to take initiative and ownership of assigned tasks, working independently with minimal supervision, yet maintain a team-oriented and collaborative approach to problem solving Previous success in a fast-paced environment Benefits Compensation: The base salary range for this position in the greater Seattle area is $28/hr - $32/hr for a level II and varies dependent on geography, skills, experience, education, and other job or market-related factors. While we are looking for level II, we may consider level III for highly qualified candidates. Disclaimer: The salary, other compensation, and benefits information are accurate as of this posting date. HMA reserves the right to modify this information at any time, subject to applicable law. In addition, HMA provides a generous total rewards package for full-time employees that includes: Seventeen (IC) days paid time off (individual contributors) Eleven paid holidays Two paid personal and one paid volunteer day Company-subsidized medical, dental, vision, and prescription insurance Company-paid disability, life, and AD&D insurances Voluntary insurances HSA and FSA pre-tax programs 401(k)-retirement plan with company match Annual $500 wellness incentive and a $600 wellness reimbursement Remote work and continuing education reimbursements Discount program Parental leave Up to $1,000 annual charitable giving match How we Support your Work, Life, and Wellness Goals At HMA, we believe in recognizing and celebrating the achievements of our dedicated staff. We offer flexibility to work schedules that support people in all time zones across the US, ensuring a healthy work-life balance. Employees have the option to work remotely or enjoy the amenities of our renovated office located just outside Seattle with free parking, gym, and a multitude of refreshments. Our performance management program is designed to elevate career growth opportunities, fostering a collaborative work culture where every team member can thrive. We also prioritize having fun together by hosting in person events throughout the year including an annual all hands, summer picnic, trivia night, and a holiday party. We hire people from across the US (excluding the state of Hawaii and the cities of Los Angeles and San Francisco.) HMA requires a background screen prior to employment. Protected Health Information (PHI) Access Healthcare Management Administrators (HMA); employees may encounter protected health information (PHI) in the regular course of their work. All PHI shall be used and disclosed on a need-to-know-basis and according to HMA's standard policies and procedures. HMA is an Equal Opportunity Employer. For more information about HMA, visit: *****************

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024. For more information, visit AmHealthPlans.com. If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application! Benefits and Perks include: * Affordable Medical/Dental/Vision insurance options * Generous paid time-off program and paid holidays for full time staff * TeleMedicine 24/7/365 access to doctors * Optional short- and long-term disability plans * Employee Assistance Plan (EAP) * 401K retirement accounts * Employee Referral Bonus Program ESSENTIAL JOB DUTIES: To perform this job, an individual must accomplish each essential function satisfactorily, with or without a reasonable accommodation. * Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials * Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standards * Work closely with delegated claim processor to ensure errors are reviewed and corrected prior to final payment * Work assigned claim projects to completion * Provide a high level of customer service to internal and external customers; achieve quality and productivity goals * Escalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and procedures * Maintain production and quality standards as established by management * Participate in and support ad-hoc audits as needed * Other duties as assigned JOB REQUIREMENTS: * Proficient in processing/auditing claims for Medicare and Medicaid plans * Strong knowledge of CMS requirements regarding claims processing, especially regarding skilled nursing facilities and other complex claim processing rules and regulations * Current experience with both Institutional and Professional claim payments * Knowledge of automated claims processing systems * Hybrid role that may require 2-3 days per week onsite at the Franklin, TN office. REQUIRED QUALIFICATIONS: * Experience: * Two (2) years' experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system * Two (2) years' experience in managed healthcare environment related to claims processing/audit * Two (2) years' experience with standard coding and reference materials used in a claim setting, such as CPT4, ICD10 and HCPCS * Two (2) years' experience with CMS requirements regarding claims processing; especially Skilled Nursing Facility and other complex claim processing rules and regulations * Two (2) years' experience processing/auditing claims for Medicare and Medicaid plans * License/Certification(s): * Coding certification preferred EQUAL OPPORTUNITY EMPLOYER Our Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made. This employer participates in E-Verify.

Description & Requirements Maximus is currently hiring for a Certification Tracking Specialist to join our Veterans Evaluation Services (VES) team. This is a remote opportunity. The Certification Tracking Specialist is responsible for maintaining a daily spreadsheet of active providers pending DMA and updates comments in NND documenting to follow up with providers until completion of DMA. - Due to contract requirements, only US a Citizen or a Green Card holder can be considered for this opportunity. Essential Duties and Responsibilities: - Maintains a daily spreadsheet of active providers pending DMA . - Update comments in NND documenting follow up with providers until completion of DMA. - Routinely communicates with PDR and PRC on status or priority providers pending DMA. - Provides feedback on providers who are struggling with DMA content to Provider Development and Retention. - Notify PDR, PRC, and Scheduling upon completion/updating of DMA. - Works closely with other teams within Provider Development and Retention for provider outreach on special projects (new DMA updates, etc.). - Assists with occasional overflow of Provider Relations Specialists and Report Tracking Specialists if needed. Additional Duties and Responsibilities: - Place and answer phone calls to and from medical providers. - Attend meetings as directed. - Work effectively within a team dynamic. - Adapt to new instructions, requests or procedures as provided. - Maintain a high sense of urgency at all times. - Other duties as assigned. Knowledge/Skills/Abilities: - Ability to read and comprehend instructions, correspondence, and memoranda. - Ability to write correspondence. - Ability to effectively present information in one- on- one and small group situations to customers, clients and other employees if the organization. - Ability to add, subtract, multiply and divide all units of measure. - Ability to compute rate, ratio and percent and to draw and interpret bar graphs. - Ability to apply common sense understanding to carry out written or oral instructions. - Ability to deal with problems. - Proficient in the following computer software: Microsoft Excel, Internet functions (searches, research), Microsoft Word, and Microsoft Outlook. Working Conditions: - Normal office environment with some exposure to moderate noise from office equipment and/or generated by staff members. - Extended hours are occasionally required beyond the regular eight hour work day. - Frequently utilizes telephone, computer, and printer; occasionally utilizes copy machine. - Occasionally lifting and/or carrying items weighing up to approximately twenty- five pounds. Generally sedentary work but requires walking up to approximately twenty- five percent of work time in carrying out job functions such as obtaining information from staff members, overseeing office and the like. - The ability to work a shift of 8:00am--4:30pm CST (Monday through Friday) is required. Home Office Requirements: Please note upon hire, Veteran Evaluation Services (VES), a Maximus Co. will provide all necessary computer equipment that is to be utilized to fulfil the duties of your role. New hires will not be exempt from using company provided equipment. Home Office Requirements Using Maximus-Provided Equipment: - Internet speed of 20mbps or higher required (you can test this by going to (1) ****************** - Connectivity to the internet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router - Private work area and adequate power source - Must currently and permanently reside in the Continental US - In accordance with SCA contract requirements, remote work must be conducted from the location specified at the time of hire. Travel is not permitted, and you are required to remain at your designated home location for all work activities. Minimum Requirements - High school diploma or general education degree (GED), or one to three months related experience and/or training, or equivalent combination of education and experience. - Previous Veterans Evaluation Service (VES) team experience preferred - Previous customer service experience preferred - Professional writing experience preferred EEO Statement Maximus is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disability, veteran status, genetic information and other legally protected characteristics. Pay Transparency For positions on this contract, Maximus will pay the prevailing wage rate for the location in which the employee is working, as determined by the Department of Labor. That wage rate will vary depending on locality. An applicant's salary history will not be used in determining compensation. Accommodations Maximus provides reasonable accommodations to individuals requiring assistance during any phase of the employment process due to a disability, medical condition, or physical or mental impairment. If you require assistance at any stage of the employment process-including accessing job postings, completing assessments, or participating in interviews,-please contact People Operations at **************************. Minimum Salary $ 17.75 Maximum Salary $ 21.17

Full Time 12238 Silicon Drive Clerical Day Shift $18.75 - $24.25 /RESPONSIBILITIES Performs adjudication of medical (HCFA) or hospital (UB92) claims for Medicaid, Commercial, and CHIP (Children's Health Insurance Program) according to departmental and regulatory requirements. Maintains audit standards as defined by the Department. EDUCATION/EXPERIENCE High school diploma or GED equivalent is required. Two or more years of experience in claim processing and/or billing experience required. Specific knowledge and experience in Medicaid, CHIP and commercial claim processing preferred. Knowledge of ICD-9, CPT 4 coding and medical terminology is required.

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job-it's a passion to serve and improve lives every day. Primary Purpose Parkland Community Health Plan's (PCHP's) 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. Minimum Specifications Education * High school diploma or equivalent required. Experience * 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 NetworX 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. * 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. Responsibilities Operations * 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 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. * Ensures high accuracy in claims adjudication to meet quality standards and maintain compliance with policies and regulations. Regulatory * 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. Professional Accountability * 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 training, self-appraisal, and annual health requirements timely. * Adheres to hybrid work schedule requirements. * Attends required meetings and town halls. * Recognizes and communicates ethical and legal concerns through the established channels of communication. * Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information. * Maintains confidentiality at all times. * Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies. Job Accountabilities 1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP. 2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices. 3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding. Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. Nearest Major Market: Dallas Nearest Secondary Market: Fort Worth Job Segment: Medicaid, Public Health, Healthcare

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job-it's a passion to serve and improve lives every day. Primary Purpose Parkland Community Health Plan's (PCHP's) 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. Minimum Specifications Education • High school diploma or equivalent required. Experience • 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 NetworX 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. • 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. Responsibilities Operations • 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 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. • Ensures high accuracy in claims adjudication to meet quality standards and maintain compliance with policies and regulations. Regulatory • 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. Professional Accountability • 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 training, self-appraisal, and annual health requirements timely. • Adheres to hybrid work schedule requirements. • Attends required meetings and town halls. • Recognizes and communicates ethical and legal concerns through the established channels of communication. • Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information. • Maintains confidentiality at all times. • Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies. Job Accountabilities 1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP. 2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices. 3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding. Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.

Description & Requirements Maximus is currently hiring for a Certification Tracking Specialist to join our Veterans Evaluation Services (VES) team. This is a remote opportunity. The Certification Tracking Specialist is responsible for maintaining a daily spreadsheet of active providers pending DMA and updates comments in NND documenting to follow up with providers until completion of DMA. - Due to contract requirements, only US a Citizen or a Green Card holder can be considered for this opportunity. Essential Duties and Responsibilities: - Maintains a daily spreadsheet of active providers pending DMA . - Update comments in NND documenting follow up with providers until completion of DMA. - Routinely communicates with PDR and PRC on status or priority providers pending DMA. - Provides feedback on providers who are struggling with DMA content to Provider Development and Retention. - Notify PDR, PRC, and Scheduling upon completion/updating of DMA. - Works closely with other teams within Provider Development and Retention for provider outreach on special projects (new DMA updates, etc.). - Assists with occasional overflow of Provider Relations Specialists and Report Tracking Specialists if needed. Additional Duties and Responsibilities: - Place and answer phone calls to and from medical providers. - Attend meetings as directed. - Work effectively within a team dynamic. - Adapt to new instructions, requests or procedures as provided. - Maintain a high sense of urgency at all times. - Other duties as assigned. Knowledge/Skills/Abilities: - Ability to read and comprehend instructions, correspondence, and memoranda. - Ability to write correspondence. - Ability to effectively present information in one- on- one and small group situations to customers, clients and other employees if the organization. - Ability to add, subtract, multiply and divide all units of measure. - Ability to compute rate, ratio and percent and to draw and interpret bar graphs. - Ability to apply common sense understanding to carry out written or oral instructions. - Ability to deal with problems. - Proficient in the following computer software: Microsoft Excel, Internet functions (searches, research), Microsoft Word, and Microsoft Outlook. Working Conditions: - Normal office environment with some exposure to moderate noise from office equipment and/or generated by staff members. - Extended hours are occasionally required beyond the regular eight hour work day. - Frequently utilizes telephone, computer, and printer; occasionally utilizes copy machine. - Occasionally lifting and/or carrying items weighing up to approximately twenty- five pounds. Generally sedentary work but requires walking up to approximately twenty- five percent of work time in carrying out job functions such as obtaining information from staff members, overseeing office and the like. - The ability to work a shift of 8:00am--4:30pm CST (Monday through Friday) is required. Home Office Requirements: Please note upon hire, Veteran Evaluation Services (VES), a Maximus Co. will provide all necessary computer equipment that is to be utilized to fulfil the duties of your role. New hires will not be exempt from using company provided equipment. Home Office Requirements Using Maximus-Provided Equipment: - Internet speed of 20mbps or higher required (you can test this by going to (1) ****************** - Connectivity to the internet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router - Private work area and adequate power source - Must currently and permanently reside in the Continental US - In accordance with SCA contract requirements, remote work must be conducted from the location specified at the time of hire. Travel is not permitted, and you are required to remain at your designated home location for all work activities. Minimum Requirements - High school diploma or general education degree (GED), or one to three months related experience and/or training, or equivalent combination of education and experience. - Previous Veterans Evaluation Service (VES) team experience preferred - Previous customer service experience preferred - Professional writing experience preferred EEO Statement Maximus is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disability, veteran status, genetic information and other legally protected characteristics. Pay Transparency For positions on this contract, Maximus will pay the prevailing wage rate for the location in which the employee is working, as determined by the Department of Labor. That wage rate will vary depending on locality. An applicant's salary history will not be used in determining compensation. Accommodations Maximus provides reasonable accommodations to individuals requiring assistance during any phase of the employment process due to a disability, medical condition, or physical or mental impairment. If you require assistance at any stage of the employment process-including accessing job postings, completing assessments, or participating in interviews,-please contact People Operations at **************************. Minimum Salary $ 17.75 Maximum Salary $ 21.17

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. This is a Full time in office position: 19100 Ridgewood Pkwy San Antonio, TX 78259 Anticipated Training Class Start Dates: 1/5/2026 or 2/2/2026 What is your impact? As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity. What Will You Be Doing: The essential functions listed represent the major duties of this role, additional duties may be assigned. Day-to-day processing of claims for accounts: Responsible for processing of claims (medical, dental, vision, and mental health claims) Claims processing and adjudication. Claims research where applicable. Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. Investigation and overpayment administration: Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. Utilize systems to track complaints and resolutions. Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading. What You Must Have: 2+ years related work experience. Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry. High school diploma or GED Knowledge of CPT and ICD-9 coding required. Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required. Must possess proven judgment, decision-making skills and the ability to analyze. Ability to learn quickly and multitask. Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers. Concise written and verbal communication skills required, including the ability to handle conflict. Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding. Review of multiple surgical procedures and establishment of reasonable and customary fees. What We Prefer: Some college courses in related fields are a plus. Other experience in processing all types of medical claims helpful. Data entry and 10-key by touch/sight What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: Medical, dental, vision, life and global travel health insurance Income protection benefits: life insurance, Short- and long-term disability programs Leave programs to support personal circumstances. Retirement Savings Plan includes employer contribution and employer match Paid time off, volunteer time off, and 11 holidays Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Get To Know Us! WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. This is a Full time in office position: 19100 Ridgewood Pkwy San Antonio, TX 78259 * Anticipated Training Class Start Dates: 1/5/2026 or 2/2/2026 What is your impact? As a Claim Examiner, you will handle processing and adjudication for healthcare claims. This will include claims research where applicable and a range of claim complexity. What Will You Be Doing: The essential functions listed represent the major duties of this role, additional duties may be assigned. * Day-to-day processing of claims for accounts: * Responsible for processing of claims (medical, dental, vision, and mental health claims) * Claims processing and adjudication. * Claims research where applicable. * Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic). * Incumbents are expected to meet and/or exceed qualitative and quantitative production standards. * Investigation and overpayment administration: * Facilitate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers. * Overpayment reviews and recovery of claims overpayment; corrected financial histories of patients and service providers to ensure accurate records. * Utilize systems to track complaints and resolutions. * Other responsibilities include resolving claims appeals, researching benefits, verifying correct plan loading. What You Must Have: * 2+ years related work experience. * Claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry. * High school diploma or GED * Knowledge of CPT and ICD-9 coding required. * Knowledge of COBRA, HIPAA, pre-existing conditions, and coordination of benefits required. * Must possess proven judgment, decision-making skills and the ability to analyze. * Ability to learn quickly and multitask. * Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers. * Concise written and verbal communication skills required, including the ability to handle conflict. * Proficiency using Microsoft Windows and Word, Excel and customized programs for medical CPT coding. * Review of multiple surgical procedures and establishment of reasonable and customary fees. What We Prefer: * Some college courses in related fields are a plus. * Other experience in processing all types of medical claims helpful. * Data entry and 10-key by touch/sight What We Can Offer YOU! To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to: * Medical, dental, vision, life and global travel health insurance * Income protection benefits: life insurance, Short- and long-term disability programs * Leave programs to support personal circumstances. * Retirement Savings Plan includes employer contribution and employer match * Paid time off, volunteer time off, and 11 holidays * Additional voluntary benefits available and a comprehensive wellness program Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for interns and part-time employees may differ. General Physical Demands: Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.

Description & Requirements Maximus is currently hiring for a Certification Tracking Specialist to join our Veterans Evaluation Services (VES) team. This is a remote opportunity. The Certification Tracking Specialist is responsible for maintaining a daily spreadsheet of active providers pending DMA and updates comments in NND documenting to follow up with providers until completion of DMA. - Due to contract requirements, only US a Citizen or a Green Card holder can be considered for this opportunity. Essential Duties and Responsibilities: - Maintains a daily spreadsheet of active providers pending DMA . - Update comments in NND documenting follow up with providers until completion of DMA. - Routinely communicates with PDR and PRC on status or priority providers pending DMA. - Provides feedback on providers who are struggling with DMA content to Provider Development and Retention. - Notify PDR, PRC, and Scheduling upon completion/updating of DMA. - Works closely with other teams within Provider Development and Retention for provider outreach on special projects (new DMA updates, etc.). - Assists with occasional overflow of Provider Relations Specialists and Report Tracking Specialists if needed. Additional Duties and Responsibilities: - Place and answer phone calls to and from medical providers. - Attend meetings as directed. - Work effectively within a team dynamic. - Adapt to new instructions, requests or procedures as provided. - Maintain a high sense of urgency at all times. - Other duties as assigned. Knowledge/Skills/Abilities: - Ability to read and comprehend instructions, correspondence, and memoranda. - Ability to write correspondence. - Ability to effectively present information in one- on- one and small group situations to customers, clients and other employees if the organization. - Ability to add, subtract, multiply and divide all units of measure. - Ability to compute rate, ratio and percent and to draw and interpret bar graphs. - Ability to apply common sense understanding to carry out written or oral instructions. - Ability to deal with problems. - Proficient in the following computer software: Microsoft Excel, Internet functions (searches, research), Microsoft Word, and Microsoft Outlook. Working Conditions: - Normal office environment with some exposure to moderate noise from office equipment and/or generated by staff members. - Extended hours are occasionally required beyond the regular eight hour work day. - Frequently utilizes telephone, computer, and printer; occasionally utilizes copy machine. - Occasionally lifting and/or carrying items weighing up to approximately twenty- five pounds. Generally sedentary work but requires walking up to approximately twenty- five percent of work time in carrying out job functions such as obtaining information from staff members, overseeing office and the like. - The ability to work a shift of 8:00am--4:30pm CST (Monday through Friday) is required. Home Office Requirements: Please note upon hire, Veteran Evaluation Services (VES), a Maximus Co. will provide all necessary computer equipment that is to be utilized to fulfil the duties of your role. New hires will not be exempt from using company provided equipment. Home Office Requirements Using Maximus-Provided Equipment: - Internet speed of 20mbps or higher required (you can test this by going to (1) ****************** - Connectivity to the internet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router - Private work area and adequate power source - Must currently and permanently reside in the Continental US - In accordance with SCA contract requirements, remote work must be conducted from the location specified at the time of hire. Travel is not permitted, and you are required to remain at your designated home location for all work activities. Minimum Requirements - High school diploma or general education degree (GED), or one to three months related experience and/or training, or equivalent combination of education and experience. - Previous Veterans Evaluation Service (VES) team experience preferred - Previous customer service experience preferred - Professional writing experience preferred EEO Statement Maximus is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disability, veteran status, genetic information and other legally protected characteristics. Pay Transparency For positions on this contract, Maximus will pay the prevailing wage rate for the location in which the employee is working, as determined by the Department of Labor. That wage rate will vary depending on locality. An applicant's salary history will not be used in determining compensation. Accommodations Maximus provides reasonable accommodations to individuals requiring assistance during any phase of the employment process due to a disability, medical condition, or physical or mental impairment. If you require assistance at any stage of the employment process-including accessing job postings, completing assessments, or participating in interviews,-please contact People Operations at **************************. Minimum Salary $ 17.75 Maximum Salary $ 21.17

Description & Requirements Maximus is currently hiring for a Certification Tracking Specialist to join our Veterans Evaluation Services (VES) team. This is a remote opportunity. The Certification Tracking Specialist is responsible for maintaining a daily spreadsheet of active providers pending DMA and updates comments in NND documenting to follow up with providers until completion of DMA. - Due to contract requirements, only US a Citizen or a Green Card holder can be considered for this opportunity. Essential Duties and Responsibilities: - Maintains a daily spreadsheet of active providers pending DMA . - Update comments in NND documenting follow up with providers until completion of DMA. - Routinely communicates with PDR and PRC on status or priority providers pending DMA. - Provides feedback on providers who are struggling with DMA content to Provider Development and Retention. - Notify PDR, PRC, and Scheduling upon completion/updating of DMA. - Works closely with other teams within Provider Development and Retention for provider outreach on special projects (new DMA updates, etc.). - Assists with occasional overflow of Provider Relations Specialists and Report Tracking Specialists if needed. Additional Duties and Responsibilities: - Place and answer phone calls to and from medical providers. - Attend meetings as directed. - Work effectively within a team dynamic. - Adapt to new instructions, requests or procedures as provided. - Maintain a high sense of urgency at all times. - Other duties as assigned. Knowledge/Skills/Abilities: - Ability to read and comprehend instructions, correspondence, and memoranda. - Ability to write correspondence. - Ability to effectively present information in one- on- one and small group situations to customers, clients and other employees if the organization. - Ability to add, subtract, multiply and divide all units of measure. - Ability to compute rate, ratio and percent and to draw and interpret bar graphs. - Ability to apply common sense understanding to carry out written or oral instructions. - Ability to deal with problems. - Proficient in the following computer software: Microsoft Excel, Internet functions (searches, research), Microsoft Word, and Microsoft Outlook. Working Conditions: - Normal office environment with some exposure to moderate noise from office equipment and/or generated by staff members. - Extended hours are occasionally required beyond the regular eight hour work day. - Frequently utilizes telephone, computer, and printer; occasionally utilizes copy machine. - Occasionally lifting and/or carrying items weighing up to approximately twenty- five pounds. Generally sedentary work but requires walking up to approximately twenty- five percent of work time in carrying out job functions such as obtaining information from staff members, overseeing office and the like. - The ability to work a shift of 8:00am--4:30pm CST (Monday through Friday) is required. Home Office Requirements: Please note upon hire, Veteran Evaluation Services (VES), a Maximus Co. will provide all necessary computer equipment that is to be utilized to fulfil the duties of your role. New hires will not be exempt from using company provided equipment. Home Office Requirements Using Maximus-Provided Equipment: - Internet speed of 20mbps or higher required (you can test this by going to (1) ****************** - Connectivity to the internet via either Wi-Fi or Category 5 or 6 ethernet patch cable to the home router - Private work area and adequate power source - Must currently and permanently reside in the Continental US - In accordance with SCA contract requirements, remote work must be conducted from the location specified at the time of hire. Travel is not permitted, and you are required to remain at your designated home location for all work activities. Minimum Requirements - High school diploma or general education degree (GED), or one to three months related experience and/or training, or equivalent combination of education and experience. - Previous Veterans Evaluation Service (VES) team experience preferred - Previous customer service experience preferred - Professional writing experience preferred EEO Statement Maximus is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, age, national origin, disability, veteran status, genetic information and other legally protected characteristics. Pay Transparency For positions on this contract, Maximus will pay the prevailing wage rate for the location in which the employee is working, as determined by the Department of Labor. That wage rate will vary depending on locality. An applicant's salary history will not be used in determining compensation. Accommodations Maximus provides reasonable accommodations to individuals requiring assistance during any phase of the employment process due to a disability, medical condition, or physical or mental impairment. If you require assistance at any stage of the employment process-including accessing job postings, completing assessments, or participating in interviews,-please contact People Operations at **************************. Minimum Salary $ 17.75 Maximum Salary $ 21.17

Department: Reimbursement Analysis Shift: First Shift (United States of America) Standard Weekly Hours: 40 The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle. Additional Information: The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP programs. The Claim Auditor I is responsible for auditing a set claim sampling on a monthly basis of routine to moderate complexity which includes paper and electronic claims submission. The Claim Auditor I ensures that claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audit reports may include UB-1450 and HCFA CMS 1500 claim forms not limited to behavioral health, physician, Institutions for Mental Disease, hospital outpatient and inpatient, and long term services and support claims. The Claim auditor is also responsible for pre-auditing high dollar claims to ensure claim payment is accurate before releasing the claim for payment. The Claim Auditor I is also responsible for communicating audit results to the Reimbursement and Analysis Manager in a structured report format within required timelines. Results of the audits are to be communicated to the Claims Department. The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle. Education/Experience: * Associates degree required or a minimum of 5 years of claims/audit experience which includes experience with federal programs (Medicaid, CHIP) or in a health plan/payor environment preferred. * 7-10 years of medical claims processing, claim adjudication, coordination of benefit plan, medical terminology and coding. * Must have strong organizational skills, problem solving and decision-making skills. * Advanced knowledge of claim adjudication and benefit plan application for Medicaid and CHIP programs. * Microsoft Office skills including Word, Excel and Access. * Excellent customer service skills with ability to explain complicated benefit issues to staff and providers. About Us: Cook Children's Health Plan Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise. Cook Children's is an equal opportunity employer. As such, Cook Children's offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination.

Department: Reimbursement Analysis Shift: First Shift (United States of America) Standard Weekly Hours: 40 The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle. Additional Information: The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP programs. The Claim Auditor I is responsible for auditing a set claim sampling on a monthly basis of routine to moderate complexity which includes paper and electronic claims submission. The Claim Auditor I ensures that claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audit reports may include UB-1450 and HCFA CMS 1500 claim forms not limited to behavioral health, physician, Institutions for Mental Disease, hospital outpatient and inpatient, and long term services and support claims. The Claim auditor is also responsible for pre-auditing high dollar claims to ensure claim payment is accurate before releasing the claim for payment. The Claim Auditor I is also responsible for communicating audit results to the Reimbursement and Analysis Manager in a structured report format within required timelines. Results of the audits are to be communicated to the Claims Department. The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle. Education/Experience: Associates degree required or a minimum of 5 years of claims/audit experience which includes experience with federal programs (Medicaid, CHIP) or in a health plan/payor environment preferred. 7-10 years of medical claims processing, claim adjudication, coordination of benefit plan, medical terminology and coding. Must have strong organizational skills, problem solving and decision-making skills. Advanced knowledge of claim adjudication and benefit plan application for Medicaid and CHIP programs. Microsoft Office skills including Word, Excel and Access. Excellent customer service skills with ability to explain complicated benefit issues to staff and providers. About Us: Cook Children's Health Plan Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise. Cook Children's is an equal opportunity employer. As such, Cook Children's offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination.

LOCATION: Remote - This is a home based, virtual position that operates Monday-Friday from 8:30am-5:00pm EST. Vaya Health welcome applications from NC, SC, GA, TN, VA, MD, and FL. GENERAL STATEMENT OF JOB Responsible for all accounting functions related to a designated area of physical and behavioral health medical claims processing to ensure that providers receive timely and accurate payment. This position is responsible for claims adjudication through continuous monitoring and quality control measures. Responsibilities include finalizing claims processed electronically for payment and reviewing claim adjudication results for both Title XIX and non-title XIX claims, payment, and denial patterns, ensuring adjudication accuracy in the claims processing system, adhering to policy and procedures, responding to provider inquiries and providing education/training to providers. ESSENTIAL JOB FUNCTIONS Claims Adjudication: This position will be responsible for finalizing claims processed for payment and maintain claims adjudication workflow, reconciliation and quality control measures to meet or exceed prompt payment guidelines. This position is responsible for reconciling provider claims payments through quality control measures, generally accepted accounting principles and Vaya's policies and procedures. This position will assess Title XIX and non-Title XIX claims adjustments for correction or recoupment and will coordinate the recoupment process to ensure payment is recovered for inappropriately paid claims. Customer Service: This position will maintain provider satisfaction by being available during regular business hours to handle provider inquiries; interacting in a professional manner; providing information and assistance; and answering incoming calls. This position will assist providers in resolving problem claims and system training issues. This position will also serve as a resource for internal staff to resolve eligibility issues, authorization, overpayments, recoupment or other provider issues related to claims payment. Compliance and Quality Assurance: This position reviews internal bulletins, forms, appropriate manuals and applicable revisions, and fee schedules to ensure compliance with established procedures and processes. Attend and participate in workshops and training sessions to improve technical competence. Miscellaneous: Other duties as assigned, including coverage of specific functions of other staff to assist the Department as work demands may dictate. KNOWLEDGE, SKILLS, & ABILITIES Must maintain a working knowledge of the Medicaid Waiver requirements, HCPCS, revenue codes, ICD-9/10, CMS-1500/UB-04 coding, compliance and software requirements used to adjudicate physical and behavioral health medical claims. Ability to handle large volume of work and to manage a desk with multiple priorities. Ability to work in a team atmosphere and in cooperation with others and be accountable for results. Ability to maintain confidential information. Ability to establish appropriate and respectful relationships/partnerships with providers served. Ability to work with a multi-disciplinary team approach. Ability to enter routine and repetitive batches of data from variety of source documents within structured time schedules. Strong organization skills. Computer proficiency, including considerable knowledge of Word and Excel programs. Ability to speak and write professionally. Ability to read printed words and numbers rapidly and accurately. Ability to understand oral and written instructions. General knowledge of office procedures and methods. QUALIFICATIONS & EDUCATION REQUIREMENTS High school diploma or GED and 4 years of experience in healthcare processing medical claims/reimbursement with experience in Physical Health and/or Behavioral Health claims. Associate Degree in Business Administration, Accounting, Finance or related field preferred. OR a combination of education and experience as follows: Graduation from a four year college/university with a major in business administration, health administration, communications or a related field may be substituted for the required experience; or a two year degree in business administration, health administration, information systems, accounting or a related field from a community college may be substituted for three of the four years of experience. PHYSICAL REQUIREMENTS Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading. Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers. Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time. Mental concentration is required in all aspects of work. RESIDENCY REQUIREMENT: The person in this position must live in NC, SC, GA, TN, VA, MD, or FL. SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation. DEADLINE FOR APPLICATION: Open Until Filled. APPLY: Vaya Health accepts online applications in our Career Center, please visit ****************************************** Vaya Health is an equal opportunity employer.

Responsible for providing breastfeeding support and nutrition education within the Special Supplemental Program for Women, Infants, and Children (WIC). Assists in cross training other employees, quality assurance/improvement and outreach. Completes certification process, issues benefits, schedule appointments and makes internal and external referrals for potential WIC participants using the WIC MIS system. Performs general office duties, maintains and audits WIC EBT card inventory, investigates dual participation and verifies transfers from other WIC projects. DUTIES AND RESPONSIBILITIES: 1. Performs nutrition assessments by obtaining and documenting applicant's diet and health history in the WIC MIS system. Completes a federally mandated risk assessment, assigns individual food packages and approves medical request for food and formula while maintaining proper documentation. Performs all duties following HHSC and local agency policies, procedures and guidelines. 2. Engages in nutrition and breastfeeding counseling, support and education services in various modalities to groups and individuals. 3. Complete certification process including activities such as goal setting, reviewing rights and responsibilities, voter's registration and making referrals to other services, as appropriate. Prepares family benefit issuance and future appointments. 4. Schedules and monitors client appointments. Request necessary documentation from applicants/participants and sends appropriate links to obtain information. Screens and documents identification, income and residence status for program eligibility. Performs general office duties, provides telephone and front desk coverage. 5. Coordinates, orders, receives, maintains office supplies and WIC forms and brochures. Audits and maintains WIC EBT card inventory. 6. Investigates dual client participation. Verifies information from other WIC projects for transfers, in state and out of state, including changes of custody. 7. Provides exceptional internal and external customer service. Greets each customer with appropriate introduction and is attentive to participants during peak wait times. Addresses concerns prior to the end of interaction. Assist other departments as appropriate. 8. Accurately obtain and document anthropometric measurements, including hemoglobin, hematocrit, and diet recalls. 9. Ensures compliance with required training to include attending conferences, meetings, and travel. Assists with training other employees, quality assurance/improvement and with outreach. 10. Performs other related duties as assigned. JOB QUALIFICATIONS: High School Diploma or GED required College level nutrition courses highly preferred Basic office skills, including filing typing, computer literacy Bilingual in English and Spanish preferred Must complete required State training designed for Formula Certified WIC Certification Specialist and modules within 9 months of hire Prior WIC experience preferred Ability to work in a team environment Certified in Basic Life Support (BLS), American Heart Association Scheduled hours and/or work locations are subject to change PHYSICAL ACTIVITIES AND REQUIREMENTS: Finger Dexterity: Using fingers to make small movements such as typing or picking up small objects. Talking: Frequently conveying detailed or important instructions or ideas accurately, clearly, or quickly. Hearing: Able to hear average or normal conversations and receive ordinary information. Repetitive Motions: Frequently and regularly using the wrists, hands, and fingers. Visual: Average, ordinary, visual acuity necessary to prepare or inspect documents or other materials. Physical: Moderate activity; assist staff and monitoring flow. May have to lift folders, files, papers, audio/video equipment, and other such items weighing up to approximately 25 lbs.

Responsible for providing breastfeeding support and nutrition education within the Special Supplemental Program for Women, Infants, and Children (WIC). Assists in cross training other employees, quality assurance/improvement and outreach. Completes certification process, issues benefits, schedule appointments and makes internal and external referrals for potential WIC participants using the WIC MIS system. Performs general office duties, maintains and audits WIC EBT card inventory, investigates dual participation and verifies transfers from other WIC projects. DUTIES AND RESPONSIBILITIES: 1. Performs nutrition assessments by obtaining and documenting applicant's diet and health history in the WIC MIS system. Completes a federally mandated risk assessment, assigns individual food packages and approves medical request for food and formula while maintaining proper documentation. Performs all duties following HHSC and local agency policies, procedures and guidelines. 2. Engages in nutrition and breastfeeding counseling, support and education services in various modalities to groups and individuals. 3. Complete certification process including activities such as goal setting, reviewing rights and responsibilities, voter's registration and making referrals to other services, as appropriate. Prepares family benefit issuance and future appointments. 4. Schedules and monitors client appointments. Request necessary documentation from applicants/participants and sends appropriate links to obtain information. Screens and documents identification, income and residence status for program eligibility. Performs general office duties, provides telephone and front desk coverage. 5. Coordinates, orders, receives, maintains office supplies and WIC forms and brochures. Audits and maintains WIC EBT card inventory. 6. Investigates dual client participation. Verifies information from other WIC projects for transfers, in state and out of state, including changes of custody. 7. Provides exceptional internal and external customer service. Greets each customer with appropriate introduction and is attentive to participants during peak wait times. Addresses concerns prior to the end of interaction. Assist other departments as appropriate. 8. Accurately obtain and document anthropometric measurements, including hemoglobin, hematocrit, and diet recalls. 9. Ensures compliance with required training to include attending conferences, meetings, and travel. Assists with training other employees, quality assurance/improvement and with outreach. 10. Performs other related duties as assigned. JOB QUALIFICATIONS: High School Diploma or GED required College level nutrition courses highly preferred Basic office skills, including filing typing, computer literacy Bilingual in English and Spanish preferred Must complete required State training designed for Formula Certified WIC Certification Specialist and modules within 9 months of hire Prior WIC experience preferred Ability to work in a team environment Certified in Basic Life Support (BLS), American Heart Association Scheduled hours and/or work locations are subject to change PHYSICAL ACTIVITIES AND REQUIREMENTS: Finger Dexterity: Using fingers to make small movements such as typing or picking up small objects. Talking: Frequently conveying detailed or important instructions or ideas accurately, clearly, or quickly. Hearing: Able to hear average or normal conversations and receive ordinary information. Repetitive Motions: Frequently and regularly using the wrists, hands, and fingers. Visual: Average, ordinary, visual acuity necessary to prepare or inspect documents or other materials. Physical: Moderate activity; assist staff and monitoring flow. May have to lift folders, files, papers, audio/video equipment, and other such items weighing up to approximately 25 lbs.