Parkland Health · 2 hours ago
Sr., Claims Examiner - PCHP
Dallas, TX
Full-time
Hybrid
Mid, Senior Level
2+ years expParkland Health is a healthcare organization seeking a Senior Claims Examiner to provide claims support by reviewing, analyzing, and researching complex health care claims. The role involves ensuring compliance with Texas Medicaid policies and PCHP guidelines while processing claims for payment in a high-volume environment.
CommunitiesHealth CareHospitalMedicalNon ProfitWellness
Responsibilities
Accurately review, process, and adjudicate medical claims in compliance with Texas Medicaid policies and PCHP guidelines
Utilize QNXT (preferred) to enter, adjust, and validate claims data. Ensure correct application of benefit plans, provider contracts, pricing schedules, and service contracts to claims adjudication
Analyze claims to confirm the appropriate use of CPT, ICD, HCPCS, and revenue codes against billed charges
Manually adjust pended or escalated claims to resolve complex issues related to provider disputes, coordination of benefits (COB), and payment errors
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
Participate in testing and training for system updates, including enhancements in QNXT and other claims processing platforms
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
Identify opportunities for workflow improvements to enhance accuracy, efficiency, and timeliness of claims adjudication
Ensures high accuracy in claims adjudication to maintain compliance with policies and regulations
Navigates various systems to ensure accurate and timely processing of claims, ultimately improving health outcomes for members
Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements
Stay up to date with Texas Medicaid regulations, CMS guidelines, and PCHP policies to ensure accurate claims processing
Assist in updating procedures and policies based on regulatory changes and system enhancements
Support claims audits and provide documentation for internal and external regulatory reviews
Promotes and supports a culturally welcoming and inclusive work environment
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 employee's 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
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
Preferred
Three (3) years of experience in healthcare claims adjudication in the QNXT platform preferred
Experience with managed care organizations (MCOs) or health plans preferred
Experience working with Texas Medicaid claims and regulatory requirements is preferred
Knowledge of NetworX Pricer for claims pricing and reimbursement is a plus
Company
Parkland Health
Parkland Health first opened its doors in 1894 and is now one of the largest public hospital systems in the country.
10001+ employees
H1B Sponsorship
Parkland Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (2)
2024 (2)
2022 (2)
Funding
Current Stage
Late StageLeadership Team
Frederick Cerise
President and Chief Executive Officer
Richard Humphrey
Executive Vice President and Chief Financial Officer
Recent News
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