Position is responsible for maintaining a claim adjudication process in compliance with CCHP, HHSC and TDI standards and contractual performance requirements. Directs the Claim adjustment process and ensures appropriate follow-through regarding any provider concerns. This position ensures State standards regarding accuracy and timing of claim payments are met.
Education & Experience:
Bachelor's degree required
Minimum of 5 years supervisory experience in claims processing for a health insurance company required. Medicaid claim processing experience preferred.
Health Care industry knowledge and operations (example: claims processing, enrollment, provider file maintenance) with ability to interpret and document business requirements.
Advanced problem solving, critical thinking, and process analysis skills to lead teams responsible for claims payment.
Project management skills
Understands the healthcare industry, including competitors, the regulatory environment, and industry trends.
Knowledge of Texas Medicaid programs
Must have knowledge of CPT, ICD-9/ICD-10, HCPCS, Revenue Codes and pricing methodologies.
Experience working with government agencies such as CMS, Medicaid, etc. along with interpreting agency and contract requirements.
Strong computer skills with proficiency in MS Word, Excel, Outlook, and Access, and Visio. PowerSTEPP and/or Tapestry claims system experience preferred.
Excellent communication skills both verbal and written.