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Parkland Health · 2 days ago

Claims Adjudicator - PCHP

Dallas, TX

Full-time

Hybrid

Entry Level

2+ years exp

Parkland Health is seeking a Claims Adjudicator for their Community Health Plans (PCHP) team, responsible for reviewing and resolving Medicaid healthcare claims within the QNXT system. The role focuses on ensuring compliance with Medicaid guidelines while maintaining high accuracy and meeting production targets.

CommunitiesHealth CareHospitalMedicalNon ProfitWellness

Responsibilities

Review and process healthcare claims within the QNXT system, ensuring compliance with benefit policies, pricing, and regulatory guidelines

Adjudicate claims accurately by analyzing supporting documentation, provider contracts, and fee schedules

Investigate and resolve pended or denied claims by applying appropriate corrections in QNXT

Collaborate with internal teams to identify, address, and resolve systemic claims issues

Meet or exceed established productivity targets for claims adjudication in a high-volume environment

Effectively prioritize and manage workload to meet deadlines and organizational objectives

Document claim outcomes, adjustments, and resolutions accurately within the QNXT system

Provide updates and insights on claims performance metrics to supervisors as needed

Integrate health literacy principles into all communication including Members and Providers

Support strategies that meet clinical, quality and network improvement goals

Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed

For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination

Ensures high accuracy in claims adjudication to meet quality standards and maintain compliance with policies and regulations

Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements

Ensure all claims are adjudicated in alignment with TMHP guidelines, Medicaid regulations, and internal policies

Promotes and supports a culturally welcoming and inclusive work environment

Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values

Adheres to organizational policies, procedures, and guidelines

Completes assigned training, self-appraisal, and annual health requirements timely

Adheres to hybrid work schedule requirements

Attends required meetings and town halls

Recognizes and communicates ethical and legal concerns through the established channels of communication

Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information

Maintains confidentiality at all times

Performs other work as requested that is reasonably related to the employees position, qualifications, and competencies

Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP

Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices

Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding

Qualification

QNXT platformTexas Medicaid claimsClaims adjudication processesNetworX PricerAnalytical skillsProblem-solving skillsMicrosoft OfficeCommunication skillsInterpersonal skillsTime managementOrganizational skillsAttention to detail

Required

High school diploma or equivalent required

Two (2) years of experience in healthcare claims adjudication required

Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines

Ability to communicate complex information in understandable terms

Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization

Excellent analytical and problem-solving skills

Proficient in adjudicating claims using QNXT, including resolution of pended or denied claims

Strong understanding of claims adjudication processes, benefit structures, and provider contracts

Familiarity with the claim's life cycle, including submission, processing, adjudication, and payment processes

Ability to identify and resolve claim discrepancies effectively and efficiently

Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities

Ability to write clearly and succinctly with a high level of attention to detail

Proficient computer and Microsoft Office skills

Ability to learn new software programs

Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual