Claims Examiner

Houston, TX 77030

Posted: 09/10/2018 Industry: Health Care Pay Rate: 20

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Task #4: Clear concise documentation/notes must be entered for each claim reviewed, which provides a historical reference of how the claim was processed at the time of adjudication.

Knowledge: Required for completely satisfactory performance in this job is a knowledge of ICD-9, CPT/HCPCS coding methodologies (and their successors); claims examination functions. High school diploma or GED required.

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