Review, investigate and provide accurate and efficient follow-up Ensure Special Projects are completed accurately, in a timely and efficient manner Participates in system testing and reviews for upgrades/implementation Identify and communicate to team, leadership, and other departments (if applicable), trends related to appeals processing, not yet addressed in a desk level procedure or identified by another team member Collaborate with Provider Relations team to educate providers regarding trends identified in appeals process Analyze potential system configuration setup issues when trending appeals to determine if modifications must be made to increase the automation of the adjudication flow Investigate and research Texas Medicaid regulatory requirements for various payment methodologies for hospitals, physicians, home health agencies, CORFs, etc., to apply to various claim scenarios where system cannot be automated Utilize expertise with federal NCCI edits, MUE edits, etc., to determine if providers are billing inappropriately or fraudulently Refer potential fraud activity to FWA unit for further investigation Evaluate the appropriateness of code bundling, un-bundling, and addition of modifiers by provider to determine if higher level of payment is warranted or if provider is upcoding. Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt Skills & Requirements HS Diploma Or GED Required 3 Years Claims Processing Experience Required * A Bachelor's degree may substitute for the required experience Founded in 1996, Texas Children's Health Plan is the nation''s first health maintenance organization (HMO) created just for children.