Claims Examiner & Support Specialist Level I

The Claims Examiner & Support Specialist Level I is responsible for accurately processing health plan delegated claims, addressing provider inquiries via phone calls, and handling various administrative tasks within the department. In addition, you will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission, Vision and Values.

Culture and Values Expectations

At HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission "to deliver quality and compassionate care with outstanding service, every patient, every time". As a (Job Title) at HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.

• Integrity: Do the right thing, the right way, every time.

• Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality.

• Compassion: Treat everyone with respect and dignity.

• Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent.

• Synergy: Collaborate to improve outcomes.

• Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas.

• Stewardship: Use resources responsibly and efficiently.

• Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.

Essential Job Duties & Responsibilities

• Processing Health Plan Delegated Claims:

• Reviewing claim submissions for accuracy and completeness.

• Verifying information provided in claims to ensure it aligns with established guidelines.

• Adjudicating claims according to the policies and regulatory guidelines set by the health plans.

• Ensuring the accurate and timely processing of delegated claims.

• Answering Phone Calls:

• Handling incoming phone calls from healthcare providers and other stakeholders.

• Providing prompt and accurate responses to inquiries related to claims processing.

• Documenting phone calls to include topics discussed and resolution.

• Addressing concerns and questions from providers regarding claims.

• Assisting with claim-related issues and resolving problems over the phone.

• Administrative Functions:

• Performing various administrative tasks to support the efficient operation of the claims processing department.

• Conducting data entry accurately and efficiently.

• Logging disputes and tracking their resolution process.

• Processing incoming mail related to claims and ensuring timely distribution.

• Handling other clerical duties as assigned by supervisors or managers.

• Other Duties as Assigned:

• Being flexible and willing to take on additional responsibilities as needed.

• Adapting to changes in workflow or procedures within the claims processing department.

• Collaborating with team members to achieve overall departmental goals.

To excel in this role, attention to detail, knowledge of healthcare claim processing, and effective communication skills are crucial. You must be familiar with the specific guidelines and policies of the health plans you are working with and stay updated on any changes. Additionally, maintaining a customer-centric approach when dealing with inquiries and issues is essential to ensure a positive experience for providers and stakeholders.

Experience

• 1 year of call center experience preferred
• 6 months claims adjudication experience preferred
• 1 year experience in Claims department is a plus

Education

• High School diploma or equivalent GED

Knowledge, Skills & Abilities

• Basic knowledge of healthcare terminology, coding, and claim processing procedures.
• Strong attention to detail and accuracy in data entry.
• Good communication skills, both written and verbal.
• Ability to adapt to changing guidelines and procedures.
• Familiarity with relevant software and computer skills for data entry and claims processing systems, a plus.
• Basic knowledge of Microsoft Office including Outlook, Word, Excel, and Teams.
• Data Entry/Typing skills, a minimum of 50 words per minute.
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers, and customers.
• Ability to multi task, as needed.

Work Hours, Travel Requirements

• Monday - Friday, 8:00 a.m. - 5:00 p.m., and as needed to complete projects.
• Travel to medical offices may be necessary for the purpose of providing benefit education.

Working Conditions & Physical Requirements

• This job operates in an office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, scanners, filing cabinets and fax machines.
• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. This is largely a sedentary role; however, some filing is required. This would require the ability to lift files, open filing cabinets and bend or stand on a stool as necessary. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.