Claims Adjudicator - PCHP
Dallas, TX
| Employer: | Parkland Health & Hospital System |
| Category: | Health Care |
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Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family. PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area. PCHP works to fulfill of our mission by empowering members to live healthier lives. By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job-it's a passion to serve and improve lives every day. Primary Purpose Parkland Community Health Plan's (PCHP's) Claims Adjudicator is responsible for reviewing, adjudicating, and resolving healthcare claims within the QNXT system. This role supports efficient claims operations, maintaining high accuracy while meeting production targets and ensuring compliance with TMHP and Medicaid guidelines. Minimum Specifications Education • High school diploma or equivalent required. Experience
Responsibilities Operations • Review and process healthcare claims within the QNXT system, ensuring compliance with benefit policies, pricing, and regulatory guidelines. • Adjudicate claims accurately by analyzing supporting documentation, provider contracts, and fee schedules. • Investigate and resolve pended or denied claims by applying appropriate corrections in QNXT. • 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. • Effectively prioritize and manage workload to meet deadlines and organizational objectives. • Document claim outcomes, adjustments, and resolutions accurately within the QNXT system. • Provide updates and insights on claims performance metrics to supervisors as needed Quality • 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. • Ensures high accuracy in claims adjudication to meet quality standards and maintain compliance with policies and regulations. Regulatory • Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements. • Ensure all claims are adjudicated in alignment with TMHP guidelines, Medicaid regulations, and internal policies. Professional Accountability • Promotes and supports a culturally welcoming and inclusive work environment. • Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values. • 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. Job Accountabilities 1. 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. 2. 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. 3. 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. Parkland Community Health Plan (PCHP) prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status. Nearest Major Market: Dallas Nearest Secondary Market: Fort Worth Job Segment: Medicaid, Public Health, Healthcare | |