Overview
As the Health Plan Claims Adjudicator for a Health Maintenance Organization (HMO), and other Health Plans based in Texas, you will be responsible for reviewing, assessing, and processing health plan claims to ensure accuracy, compliance with regulations, and adherence to company policies. The Health Plan Claims Adjudicator processes professional and institutional health plan claims utilizing the Health Plan’s claim systems, policies, and procedures to confirm eligibility and accurate processing.
Responsibilities
Essential Functions:
- Conduct review and evaluation of health plan claims received electronically and via mail
- Assessing eligibility and benefits before claims payment process to confirm if the claim is eligible for payment or should be denied due to discrepancies and errors
- Review each claim to prevent fraud and coordinate with Compliance, Claims Auditor and Claims Manager as needed
- Stay abreast of Claims System software updates
- Support Claim Appeals and Claims Finance
- Collaborating with Claims Management Team or other Health Plan Teams to ensure adjudication accuracy when needed
Knowledge, Skills and Abilities:
- Strong understanding of healthcare claims processing principles, coding systems, and reimbursement method
- Proficiency in utilizing claims processing software and systems (VBA preferrable)
- Knowledge of healthcare regulatory compliance requirements, including HIPAA, CMS guidelines, and Texas regulations
- Analytical mindset with the ability to interpret complex data, identify trends, and recommend datadriven solutions
Qualifications
Minimum Education: High School Diploma or equivalent (higher degree accepted)
Minimum Experience: 5 years of experience in health plan claims adjudication, preferably within an HMO or managed care environment required.
Virtual Benefits Administrator (VBA) experience preferred.
