Claims Quality & Data Analytics Auditor

Parkland Community Health Plan, Inc.; Dallas (TX); On-site; USD 65,000 - 95,000; Full time

Job summary

Parkland Community Health Plan, Inc. seeks a Claims Quality Auditor to review, analyze, and adjudicate professional claims, appeals, corrected claims, and refunds for Parkland-covered patients.

You will ensure accuracy, compliance with business rules, and provide actionable insights to leadership using EPIC-derived eligibility data. You will perform QA on TPA-processed claims, generate trends reports, and collaborate with IT and external vendors to implement process improvements and uphold

Qualifications

• Bachelor's degree in health or finance-related field required.
• Five years of experience in accounting, business office, or medical insurance claims environment in a large volume setting.
• Experience with Medicare billing/reimbursement rules and regulations.
• Experience with large data management.
• Experience with Texas Medicaid program eligibility guidelines.
• Knowledge of ICD10, CPT coding/billing operations, and medical terminology.
• Preferred EPIC software experience.
• Preferred SQL reporting skills (Crystal Reports).

Responsibilities

• Analyzes, documents, and adjudicates monthly claims data, appeals, corrected claims and refunds for professional clinical services for Parkland covered patients.
• Performs a detailed quality assurance of claims processed by the Third-Party Administrator (TPA).
• Generates patient eligibility and coverage reporting from EPIC and validates patient\'s unfunded status.
• Provides data management support and creates custom reports to illustrate claim adjudication trends and issues for administration.
• Implements recommended revisions to processes or TPA system setup to streamline claim, appeals and refunds adjudication.
• Identifies trends in TPA errors and reports them to the Manager of Department Systems with corrective measures.
• Coordinates with IT and the UT Southwestern Finance team to ensure adherence to contract business rules.
• Works with large data for ad hoc reporting and trend analysis for UT Contracts Team.

Skills

5+ years of experience in claims

Medicare billing rules

Texas Medicaid eligibility guidelines

ICD10, CPT coding

SQL reporting

EPIC software

Microsoft Excel

Microsoft Word

PowerPoint

Access

Visio

Education

Bachelor's degree in health or finance-related field

Tools

Crystal Reports

EPIC software

Job description

Parkland Community Health Plan, Inc. seeks a Claims Quality Auditor to review, analyze, and adjudicate professional claims, appeals, corrected claims, and refunds for Parkland-covered patients.

You will ensure accuracy, compliance with business rules, and provide actionable insights to leadership using EPIC-derived eligibility data. You will perform QA on TPA-processed claims, generate trends reports, and collaborate with IT and external vendors to implement process improvements and uphold