Sr. Claims Examiner - The Health Plan

Position: Sr. Claims Examiner - The Health Plan

Job ID: 147727

Location: US-TX-Bellaire

Department: Claims - Examination

Talent Area: Clerical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p Monday - Friday

About Texas Children's Hospital

Texas Children’s Health Plan (TCHP) is the largest Texas Medicaid managed care organization, and is part of the Texas Children’s healthcare system. Founded in 1996, TCHP is the nation's first health maintenance organization (HMO) created just for children and pregnant women. Our plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. Currently the Health Plan serves more than 450,000 members across three service areas (Harris, Jefferson, North East). Members of the plan receive care from our network of more than 4,000 primary care physicians, 8,000 specialists, and 110 hospitals. They can also receive care at The Center for Children and Women, a patient and family-centered medical home with two convenient locations for TCHP members who can have all their medical needs met in one place, receiving multiple services the same day. TCHP is a recognized leader at encouraging holistic care that empowers families to live healthier lives.   To join our community of 13,000 dedicated team members, visit for career opportunities.   You can also learn more about our amazing culture at


We are searching for a Sr. Claims Examiner - someone who works well in a fast-paced hospital setting. In this position, you’ll process and adjudicate claims received for reimbursement to Providers based on extensive review, research and a detailed format of claim processing procedures. Additionally, you’ll make routine decisions including claims adjudication within the appropriate levels of authority.



Think you’ve got what it takes?

Responsibilities :

  • Adjudicate claims received into processing system
  • Thoroughly reviews, investigates and adjudicates claims daily, working oldest to newest claim in 30 days or less, and 98% of the time
  • The claims are processed accurately as defined by standard guidelines
  • The claims should be adjudicated with a 98% procedural accuracy rate monthly as reviewed by weekly audit reports
  • Special projects as requested
  • Examiner should process a minimum of 14 claims per hour, or a minimum of 98 claims per day
  • The claims should be adjudicated with a 98% accuracy rate monthly as reviewed by returned claims for adjustment review
  • Conducts review and investigation of pended claims and follow up with internal and external departments to finalize claims resolution within 30 days
  • The claims that are manually adjudicated must have notes entered as reviewed by weekly audits, check run, returned claims, management review 98% of the time
  • Access requests are processed within 30 days of receipt, with a 98% accuracy, to ensure timely resolution of claims, in adherence with HHSC regulatory requirements
  • Supports Supervisor of Claims Administration
  • Coordinates and completes check run processes.


  • High school diploma or GED
  • Two years claims examination experience

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