Claims Resolution Specialist Internal Resolution Unit- Health Plan

PCHP- Parkland Health Plan

Primary Purpose

Responsible for investigating, analyzing, and resolving complex claims and payment disputes. This role ensures accurate claims adjudication by reviewing provider disputes, member grievances, and payment discrepancies. Collaborates with cross-functional teams to ensure compliance with federal and state regulations while driving process improvements to enhance operational efficiency.

Minimum Specifications

Education

• High School Diploma required.
• Bachelor's degree in business administration, accounting, finance or a related field is preferred.

Experience

Required:

• Three (3) years of experience in claims adjudication, dispute resolution, or Medicaid managed care.
• Strong knowledge of Texas Medicaid policies, guidelines, and claims processes.

Preferred:

• Experience with provider contract management and claims systems (QNXT).
• Familiarity with auditing and root cause analysis in a healthcare setting.
• Experience working with coding and billing systems, including claims processing platforms.

Skills or Special Abilities

• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization.
• Excellent analytical and problem-solving skills.
• Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Ability to write clearly and succinctly with a high level of attention to detail.
• Proficient computer and Microsoft Office skills. Ability to learn new software programs.
• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Responsibilities

Operations

• Investigate and resolve complex claims and payment disputes, ensuring compliance with Texas Medicaid policies and contractual obligations.
• Conduct root cause analysis to identify patterns of errors or trends in disputes and recommend process improvements.
• Review provider contracts, billing guidelines, and payment policies to ensure proper adjudication of claims.
• Respond to provider and member inquiries regarding claims resolutions, payment adjustments, and dispute outcomes.
• Analyze claims data to detect discrepancies, identify resolutions, and ensure accurate payments.
• Collaborate with internal departments (e.g., Provider Relations, Compliance, Finance, Claims and Configuration etc.) to resolve escalated cases.
• Provide recommendations for system or process enhancements to improve claims resolution accuracy and efficiency.
• Monitor and track dispute resolution timelines to ensure timely responses and compliance with organizational standards.
• Document findings and resolutions in accordance with internal policies and regulatory requirements

Regulatory and Compliance

• Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

Quality

• Identifies ways to improve work processes and enhance customer satisfaction.
• 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.

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

• 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.
• 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.
• 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.