Claims Examiner

TCH Medical Center; Bellaire (TX); On-site; USD 40,000 - 60,000; Full time

Job summary

TCH Medical Center is seeking a Claims Examiner to support our growing team. You will process and adjudicate claims for reimbursement to Providers based on our detailed claim processing procedures.

You will thoroughly review, investigate, and adjudicate claims daily, aiming to resolve oldest claims within 30 days with high accuracy and efficiency, targeting 98% accuracy in audits.

Examiners are expected to maintain clear documentation and complete special projects as requested.

Qualifications

• Requires HS diploma or GED.
• At least 1 year claims examination experience.

Responsibilities

• Adjudicate claims received into processing system.
• Thoroughly review, investigate, and adjudicate claims daily with 30-day resolution goal.
• Process at least 14 claims per hour or 98 per day with accuracy.
• Follow up on pended claims to finalize resolution within 30 days.
• Ensure 98% accuracy per monthly audits and ongoing notes for each claim.
• Enter clear, concise documentation for each adjudicated claim.
• Complete special projects as requested.

Skills

Claims processing

Adjudication

Documentation

Education

High School Diploma or GED

Job description

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

Think you've got what it takes?

Job Duties & Responsibilities

• Adjudicate claims received into processing system.
• Thoroughly reviews, investigates, and adjudicates claims daily, working oldest to newest claim in 30 days or less, and 98% of the time.
• Examiners should process at least 14 claims per hour, or 98 claims per day.
• Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days.
• Macess requests are processed within 30 days of receipt, with a 98% accuracy, to ensure timely resolution of claims, in adherence with HHSC regulatory requirements.
• The claims are processed accurately as defined by standard guidelines.
• The claims should be adjudicated with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports.
• The claims should be adjudicated with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review.
• The claims that are manually adjudicated must have notes entered as reviewed by weekly audits, check run, returned claims, management review 98% of the time.
• Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication.
• Complete special projects as requested.

Skills & Requirements

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