Claims Adjudicator - PCHP

Are you looking for a career that offers both purpose and the opportunity for growth? Parkland Community Health Plan (PCHP) is a proud member of the Parkland Health family.  PCHP is a Medicaid Managed Care Organization servicing Texas Medicaid and CHIP in the Dallas Service Area.  PCHP works to fulfill of our mission by empowering members to live healthier lives.  By joining PCHP, you become part of a team focused on innovation, person-centered care, and fostering stronger communities. As we continue to expand our services, we offer opportunities for you to grow in your career while making a meaningful impact. Join us and work alongside a talented team where healthcare is more than just a job—it’s a passion to serve and improve lives every day.

Primary Purpose

Parkland Community Health Plan’s (PCHP’s) Claims Adjudicator is responsible for reviewing, adjudicating, and resolving healthcare claims within the QNXT system. This role supports efficient claims operations, maintaining high accuracy while meeting production targets and ensuring compliance with TMHP and Medicaid guidelines.

Minimum Specifications

Education

• High school diploma or equivalent required.

Experience

• Two (2) years of experience in healthcare claims adjudication required.
• Expertise in the QNXT platform preferred.
• Experience working with TMHP claims and Medicaid regulatory requirements is preferred. • Knowledge of NetworX Pricer for claims pricing and reimbursement is a plus.
• 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.
• Proficient in adjudicating claims using QNXT, including resolution of pended or denied claims.
• Strong understanding of claims adjudication processes, benefit structures, and provider contracts.
• Familiarity with the claim's life cycle, including submission, processing, adjudication, and payment processes.
• Ability to identify and resolve claim discrepancies effectively and efficiently.
• 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

• Review and process healthcare claims within the QNXT system, ensuring compliance with benefit policies, pricing, and regulatory guidelines.

• Adjudicate claims accurately by analyzing supporting documentation, provider contracts, and fee schedules.

• Investigate and resolve pended or denied claims by applying appropriate corrections in QNXT.

• Collaborate with internal teams to identify, address, and resolve systemic claims issues. • Meet or exceed established productivity targets for claims adjudication in a high-volume environment.

•Effectively prioritize and manage workload to meet deadlines and organizational objectives.

• Document claim outcomes, adjustments, and resolutions accurately within the QNXT system.

• Provide updates and insights on claims performance metrics to supervisors as needed

 Quality

 • 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.

• Ensures high accuracy in claims adjudication to meet quality standards and maintain compliance with policies and regulations.

 Regulatory

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

• Ensure all claims are adjudicated in alignment with TMHP guidelines, Medicaid regulations, and internal policies.

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

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 Community Health Plan (PCHP) 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.