We are a local, non-profit managed care company that cares about the community we serve. Our health plan offers coverage through the Texas CHIP, STAR, and STAR Kids Medicaid programs to more than 130,000 members in the 6-county Tarrant service area (Tarrant, Johnson, Denton, Parker, Hood, and Wise). We offer quality, affordable plans for low-income pregnant women and families with children, including those with significant medical complexity. Our network includes thousands of doctors, clinics, hospitals, and specialty service providers. Our member and provider satisfaction scores demonstrate our commitment to elevating every experience for our members, providers and staff.
Position is responsible for managing the personnel and processes for the Claims Intake, Rework, Appeals Processing and the Provider Phone Inquiry team. Primary duties include, but are not limited to: 1. Managing the claims intake paper to electronic claim process in compliance with the State contract 2. Managing claims rework and appeals process and turn-around time in compliance with the State contract 3. Managing call center operations including answering phones, faxes, e-mails and responding to provider and billing office inquiries relating to Claims and Benefits. 4. Perform and/or coordinate claims research related to claim issues 5. Hire, train coach and evaluate performance of direct reports 6. Track and report staff metrics to leadership 7. Establish and maintain departmental policies and procedures 8. Perform audits to monitor efficiency and compliance with policies 9. Professionally communicate and collaborate across all functional areas of the Health Plan.
Education & Experience:
High School diploma or equivalent
Will substitute 10 years experience for Bachelors Degree. 3-5 years supervision experience.
Five years’ experience in a medical claims processing environment.
Must be extremely detail-oriented, precise, and thorough.
Extensive knowledge of medical claim processing procedures and guidelines.
Ability to work independently while providing support to a team environment.
Extensive knowledge of medical benefits and medical terminology.
Must have strong organizational skills, problem solving, and decision making skills.
Strong knowledge of claim adjudication and benefit plan application for Texas Medicaid.
Knowledge of commercial insurance provisions.
Able to process adjustments as needed.
Knowledge of Microsoft Office Skills including Word, and Excel.
Licensure, Registration, and/or Certification:
Medical Coding Certification, or ability to obtain within two years of assuming this position
Internal Number: 52043-44382
About Cook Children's Health Care System
Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities – a Medical Center, Physician Network, Home Health company, Northeast Hospital, Pediatric Surgery Center, Health Plan, Health Services Inc., and Health Foundation.Cook Children's Medical Center Based in Fort Worth, Texas, the integrated system has more than 60 primary and specialty care offices throughout North Texas. Its service region includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties, with an additional referral area encompassing nearly half the state.Cook Children's traces its roots back to 1918, but throughout its continual change and robust growth, it still embraces an inspiring promise – to improve the health of every child in its region through the prevention and treatment of illness, disease and injury. To live up to this promise, Cook Children's combines the art of caring with the use of leading technology and extraordinary collaboration to provide exceptional care for every child, every day.History – Cook Children's has a rich history of nearly a century of caring for children.Our Promise – Knowing that every child's ...life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.Companies – Based in Fort Worth, Texas, Cook Children's is a not-for-profit organization that is comprised of eight nationally recognized companies.Community Health Outreach – Cook Children's Community Health Outreach works together with over 150 partner organizations to improve the safety and health of at-risk children through education, disease and injury prevention and support.Clinical Research – Cook Children's is home to a skilled team of research-minded physicians, nurses and health care professionals and administrators who drive our commitment to excellent clinical care and the search for medical advances.Public Relations – Cook Children's Public Relations works with national and local media outlets, produces Cook Children's publications, coordinates special events and helps develop key relationships within the community.Contractor & Vendor Information – Cook Children's contractors and vendors must ensure their employees are knowledgeable about working with our organization.Sponsorship guidelines – Cook Children's sponsors a select number of events that are strongly aligned with its promise to improve the health of every child in the region through the prevention and treatment of illness, disease and injury.