Claims & Encounters Resolution Specialist-PCHP

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that’s served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It’s our passion.

Primary Purpose:

Parkland Community Health Plan's (PCHP's) Claims and Encounters Resolution Specialist will serve as PCHP's claims and encounters subject matter expert and is responsible for the coordination and timely resolution of claim and encounter issues. The Claims and Encounters Resolution Specialist will also be responsible for monitoring key performance indicators and will partner with various PCHP departments and vendors on the implementation of new programs and products.


Minimum Specifications:


- High School diploma or equivalent is required.

- Bachelor's degree in business administration, accounting, finance or a related field is preferred.



- Three years of experience in claims processing or claims data resolution in a health care organization.

- Experience in Medicaid Claims Encounters for the State of Texas is preferred.

- Strong experience working with claim encounters and/or HIPAA X12 (EDI) transactions is preferred.

- Experience with QNXT or FACETS claims system is preferred.

- Experience in a Health Plan or Managed Care Organization (MCO) is preferred.


Skills or Special Abilities

- Knowledge of HCFA 1500 and UB04 billing forms and related data interpretation.

- Strong working knowledge of health insurance concepts, practices and procedures including understanding of provider payment methodologies and claims processing workflows, from receipt through final adjudication.

- Strong analytical and research abilities to triage issues and perform reconciliations or data analysis. - Working knowledge of Federal and State regulatory rules regarding claims adjudication.

- Ability to identify root cause for issues and incorporate findings into process improvement initiatives.

- Detail oriented and able to work issues to resolution.

- Excellent verbal and written communication skills to interact with internal and external stakeholders.

- Strong organizational skills and the ability to manage multiple competing projects and deadlines.

- Proficiency with Microsoft Office Excel, Word, and Outlook is required.

- Demonstrated ability to collaborate effectively and work as part of a team in a fast-changing environment.

- Strong knowledge of Texas State Medicaid Guides & Handbooks

- TMHP Provider Manuals, Uniform Managed Care Contract (UMCC), Uniform Managed Care Manual (UMCM), etc. is preferred. Responsibilities

- Leads the efforts of researching and resolving claims and claim encounter issues in a timely manner.

- Resolves issues related to claims and encounters through end to end review (data received, loaded, processed, reported, etc.).

-Identifies the cause of the issue and resolves through collaboration with all departments and individuals involved in the area of the identified concern.

- Provides information requested and resolves problems that arise involving claims.

- Serves as PCHP's subject matter expert for claims and claim encounters.

- Monitors claims and encounters key performance metrics and escalates issues when warranted.

- Partners with PCHP departments and vendors on the implementation of new programs and products.

- Communicates, collaborates and cooperates with internal and external stakeholders in a respectful and responsible manner.

- Adheres to all compliance requirements and complies with HIPAA regulations.

- Performs other duties or special projects as assigned.


Job Accountabilities:

1. 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.

2. 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.

3. 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.

Parkland Health and Hospital System prohibits discrimination based on age (40 or over), race, color, religion, sex (including pregnancy), sexual orientation, gender identity, gender expression, genetic information, disability, national origin, marital status, political belief, or veteran status.

Salary Range
$24,000.00 - 33,000.00
per Year
Salary range estimated by
Dallas, TX 75201, US