Senior Claims Analyst

20 Driscoll Children's Health Plan; Corpus Christi (TX); On-site; USD 65,000 - 85,000; Full time

Job summary

Driscoll Health System is seeking a Senior Claims Analyst to perform highly complex analysis for research, resolution, and recovery of health plan claims. The role supports department projects and ensures systems enable timely, compliant claims processing.

A subject matter expert on claims policies and procedures, you will mentor staff and drive process improvements. Candidates should have extensive claims analysis or medical billing experience, including Medicaid familiarity, and be prepared to

Qualifications

• Minimum five years professional experience in claims analysis, provider billing or coding.
• Two years in claim research, adjustment and recovery; Texas Medicaid preferred.
• High school diploma or GED required.

Responsibilities

• Analyze highly complex claims to ensure correct payments; collaborate with partners.
• Identify trends and recommend solutions for errors and recoveries.
• Support daily inventory planning and prioritize timely resolutions.
• Review provider correspondence to determine correct outcomes and escalate high risk issues.
• Lead departmental projects and process improvement initiatives.
• Ensure data integrity, security, and process optimization across operations.
• Ensure adherence to compliance, reimbursement and contract policies.
• Mentor staff, provide feedback, and lead training for new employees.
• Participate in team meetings with ideas to improve efficiency and quality.

Skills

Claims analysis

Provider billing

Medical coding

Texas Medicaid

Claim research

Process improvement

Education

High school diploma or GED

Texas Medicaid experience (preferred)

Job description

Where compassion meets innovation and technology and our employees are family. Thank you for your interest in joining our team! Please review the job information below. The Senior Claims Analyst will be responsible to perform highly complex and technical analysis for research, resolution and recover of health plan claims. The position is also responsible to departmental and project coordination for issues resolution and process improvement, and helps to ensure that systems, processes and reports enable the Claims Administration department to meet internal and external benchmarks. The position additionally serves as a subject matter expert regarding claims related policies and procedures.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Individuals in this position may perform and or all the below listed duties. These should be interpreted as examples of the work and are not necessarily all inclusive.
• 1. Analyze highly complex claims and claim issues to ensues to ensure correct claims payment, partner with Claims Administration and staff and health plan business partners for resolution.
• 2. Identify trends and recommend solutions for errors as identified through pre- and post-payment claim and recover review.
• 3. Assist with department leadership to develop daily inventory plans based on available resources, priority, and timeliness requirements.
• 4. Analyze provider correspondence and requests for review to determine correct outcomes and resolution, escalating high priority/risk issues to leadership.
• 5. Lead departmental projects and/or operational improvement initiatives.
• 6. Assist in the examination, assessment, and business documentation of operations and procedures to ensure data integrity, security, and process optimizations.
• 7. Ensure adherence to state and federal compliance, reimbursement and contract policies.
• 8. Provide mentoring and coaching to team members, provide assistance and feedback to less experienced staff members, and lead training efforts for new employees.
• 9. Openly participate in team meetings, providing ideas and suggestions to ensure departmental efficiency and quality, and to promote teamwork.
• 10. Maintain required compliance with privacy and confidentiality standards.
• 11. Maintain or exceed all established standards for performance, quality and timeliness.
• 12. Demonstrate business practices and personal actions that are ethical and adhere to all Health System and Health Plan policies and procedures.
• 13. Assist with other related work responsibilities as requested.

EDUCATION AND/OR EXPERIENCE

• Any combination of education and experience that would likely provide the required knowledge, skills, and abilities is qualifying.
• Minimum five years professional experience in claims analysis, provider medical billing, or medical coding experience with Texas Medicaid preferred.
• Minimum two years professional experience with Claim research, adjustment and recover; experience with Texas Medicaid preferred.
• Minimum High school graduate or GED required.

Until all children are well. Driscoll Children’s Hospital and its specialty centers, urgent care centers, and after-hours facility serve a vast area covering 31 South Texas counties. The hospital is a 191-bed tertiary care center offering 32 medical and 13 surgical specialties. Combined with our non-profit, community-based Health Plan, Driscoll Health System is an exceptional workplace for anyone with a big heart and a drive for success. Smiles, hugs and a soothing touch are as much a part of Driscoll’s approach to treating children as is its advanced medical treatments and technologies. The core values at Driscoll Heath System are: Compassion, Advocacy, Respect, Excellence, and Stewardship. These values are exemplified through every position - from treating the most critical patients hands-on, to maintaining a clean environment, to keeping the organization running from behind the scenes. We invite you to learn about Driscoll’s rich history and explore the laidback lifestyle South Texas has to offer.

Core values at Driscoll Heath System

• Compassion
• Advocacy
• Respect
• Excellence
• Stewardship