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 both professional and institutional health plan claims utilizing the Health Plan's claim systems and policies and procedures to confirm eligibility and accurate processing.

ESSENTIAL FUNCTIONS:

• Review, evaluate, and process health plan claims received electronically and via mail.
• Assess eligibility and benefits prior to claims payment process to confirm if a claim is eligible for payment or should be denied due to discrepancies or errors.
• Make recommendations for resolutions of all health plan claims.
• Examine and analyze each claim to prevent fraud and coordinate with Compliance, Claims Auditor and Claims Manager as needed.
• Study and compare reports of similar claims to determine the extent of insurance coverage and evaluate completeness and validity of the claim.
• Determine settlement according to organization practices and procedures.
• Ensure compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
• Stay abreast of Claims System software updates.
• Collaborate with the Claims Management Team or other Health Plan Teams to ensure adjudication accuracy when needed.
• May perform other duties as assigned.

KNOWLEDGE/SKILLS/ABILITIES:

• Thorough understanding of health plan claims processing principles, coding systems, and reimbursement methods.
• Proficiency in utilizing claims processing software and systems (VBA preferrable).
• Knowledge of health plan regulatory compliance requirements, including HIPAA, CMS guidelines, and Texas regulations.
• Analytical mindset with the ability to interpret complex data, identify trends, and recommended data driven solutions.
• Strong attention to detail.
• Ability to think analytically and problem-solve.
• Ability to effectively prioritize tasks and assignments.
• Excellent written and verbal communication skills.
• Working knowledge of medical terminology and abbreviations.

EDUCATION:

• High School Diploma required.
• Bachelor's Degree in Healthcare Administration, Business Management, or related field preferred.

EXPERIENCE:

• 3 years experience in Health Plan claims adjudication, preferably with an HMO or managed care environment required.