Claims Educator/Auditor - The Health Plan

 
Position: Claims Educator/Auditor - The Health Plan

Job ID: 145828

Location: US-TX-Houston

Department: Claims - Training/Specialists

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p Monday - Friday

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 13,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.

Summary:

We are searching for a Claims Educator/Auditor - someone who can thrive in a fast-paced managed care environment. In this position, you’ll lead in the design, development, and implementation of training programs for new and existing employees, to enhance the competency, performance and professional development of the Claims Administration team. This position is critical in the development and ongoing accuracy of claims processing to ensure accurate reimbursement to Providers.

 

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Responsibilities :

Job Duties & Responsibilities

  • Designs and Develops Training manual and desktop procedures to encompass the major areas of Claims Administration including: Data Entry, mailroom and claims examination
  • Conducts training program to provide an effective and interactive learning environment to achieve departmental goals and objectives utilizing innovative, professional communication methods
  • Assures that staff completes Health Plan and departmental orientation upon employment as monitored by training records
  • Documents competency scores for Pre & Post Assessments to ensure comprehension of material presented to employees
  • Provides staff with ongoing job-specific training programs, in services and continuing education opportunities
  • Develops and completes measurable job-specific training as identified by statistical reports and audits
  • Collects and evaluates feedback on training program initiatives and makes recommendations for improvement
  • Completes random audits, consistent with industry standards, of each claim examiner and claim specialist’s completed claims processing to review accuracy and appropriateness of the finalized claims
  • Completes at least annually, or as required, on-site audits of Health Plan delegated entities performing claims processing functions
  • Completes weekly audit of Data Entry personnel to ensure accurateness of data entry
  • Develops and Compiles weekly and monthly statistical report and trend analysis of error ratios identified in audits for claims processing functions for Claim Management review
  • Performs specific training on Information Systems used in Claims Administration
  • Recommends Application and Program enhancements to improve workflow processes
  • Coordinates and facilitates all aspects of end-user testing for system updates/conversions


Qualifications:

Requirements

  • Associate’s Degree
  • A minimum of two (2) years of previous training experience in a claims administration area
  • Ability to communicate effectively both oral and written and good interpersonal skills
  • Decision-making skills
  • Professional courtesy
  • Ability to operate a PC and general office equipment
  • Knowledge of medical terminology, ICD- 9 codes, CPT/HCPCS coding methodologies (and their successors) and general principles with claims processing requirements


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