Senior Health Plan Claims Adjudicator

Job description

Overview As the Health Plan Claims Adjudicator for a Health Maintenance Organization (HMO), and other Health Plans based in Texas, you will be responsible for reviewing, assessing, and processing health plan claims to ensure accuracy, compliance with regulations, and adherence to company policies. The Health Plan Claims Adjudicator processes professional and institutional health plan claims utilizing the Health Plan’s claim systems, policies, and procedures to confirm eligibility and accurate processing. Responsibilities: Essential Functions: - Conduct review and evaluation of health plan claims received electronically and via mail - Assessing eligibility and benefits before claims payment process to confirm if the claim is eligible for payment or should be denied due to discrepancies and errors - Review each claim to prevent fraud and coordinate with Compliance, Claims Auditor and Claims Manager as needed - Stay abreast of Claims System software updates - Support Claim Appeals and Claims Finance - Collaborating with Claims Management Team or other Health Plan Teams to ensure adjudication accuracy when needed Knowledge, Skills and Abilities: - Strong understanding of healthcare cla...