Claims Examiner

Job Title: Claims Examiner/Adjuster
Location: Houston, TX 77401 (Hybrid)
Duration: 4+ Months contract (Possible Extension)
Shift: 7:30 AM 4:30 PM or 8 AM 5 PM Central Time

Job Description:
Responsibility A: Adjudicate Claims received into processing.

• Task #1: Thoroughly reviews, investigates, and adjudicates claims daily, working oldest to newest claim in 30 days or less, and 98% of the time.
• Task #2: Examiner should process a minimum of 14 claims per hour, or a minimum of 98 claims per day.
• Task #3: Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days.
• Task 4: 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.

Responsibility B: The claims are processed accurately as defined by standard guidelines.

• Task #1: The claims should be adjudicated with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports.
• Task #2: The claims should be adjudicated with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review.
• Task #3: 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.
• Task #4: Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication.

Skills:
Required for completely satisfactory performance in this job is a knowledge of ICD-9, CPT/HCPCS coding methodologies (and their successors), claims examination functions.

Education:

• High School Diploma or GED
• 2 years claims experience.