Claims/Benefits Specialist

Department: Claims - Training/Specialists Shift: Hybrid-Monday-Friday 8a-5p Job ID: 425335 We are searching for a Claims Benefits Specialist — someone who works well in a fast-paced setting. In this position, you will investigate and accurately process claim appeals within the regulatory requirements mandated by the State of Texas. Job Duties & Responsibilities Process Specialists Adjustments, Replacements, Refunds, and Appeals Queues, Group queues content at 98% average, within 30 days of receipt Review and process pended claims, within 5 days of initial review Respond to internal inquiries within 48 hours of receipt. Review, investigate and provide accurate and efficient follow-up Ensure Special Projects are completed accurately, in a timely and efficient manner Participate in system testing and reviews for upgrades/implementation Identify and communicate to team, leadership, and other departments (if applicable), trends related to appeals processing, not yet addressed in a desk level procedure or identified by another team member Collaborate with Provider Relations team to educate providers regarding trends identified in appeals process Analyze potential system configuration setup issues when trending appeals to determine if modifications must be made to increase the automation of the adjudication flow Investigate and research Texas Medicaid regulatory requirements for various payment methodologies for hospitals, physicians, home health agencies, CORFs, etc., to apply to various claim scenarios where system cannot be automated Utilize expertise with federal NCCI edits, MUE edits, etc., to determine if providers are billing inappropriately or fraudulently Refer potential fraud activity to FWA unit for further investigation Evaluate the appropriateness of code bundling, un-bundling, and addition of modifiers by provider to determine if higher level of payment is warranted or if provider is upcoding. Refers trends of inappropriate activity for further data analytics for potential fraud Process and coordinate claims identified by the Fraud, Waste & Abuse (FWA) department for retraction and/or reprocessing Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt Skills & Requirements HS Diploma Or GED Required 3 Years Claims Processing Experience Required A Bachelor’s degree may substitute for the required experience Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved. #J-18808-Ljbffr Texas Children's Hospital