What are the responsibilities and job description for the Claims Clerk position at HealthTexas?
The Claims Clerk is responsible for performing clerical and administrative duties that support the efficient operation of the claims department, including claims intake, documentation management, EDI support, vendor correspondence, and other duties as assigned.
In addition, you will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission, Vision and Values.
Culture and Values Expectations
At HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission “to deliver quality and compassionate care with outstanding service, every patient, every time”. As a Billing Specialist at HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.
- Integrity: Do the right thing, the right way, every time.
- Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality.
- Compassion: Treat everyone with respect and dignity.
- Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent.
- Synergy: Collaborate to improve outcomes.
- Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas.
- Stewardship: Use resources responsibly and efficiently.
- Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.
Essential Job Duties & Responsibilities
- Vendor Communication
- Answering phones, addressing vendor inquiries, redirecting the vendor to the portal, or redirecting calls to the appropriate person/department.
- Claims Intake & System Support
- Data entry of paper claims.
- Monitor clearinghouse reports for rejected or failed claim submissions and escalate issues for resolution.
- Perform EDI claim file uploads, verify successful transmission, and monitor for failed intake, addressing issues or escalating as appropriate.
- Refunds, Recoupments, & Reconsiderations
- Assist with tracking and logging vendor reconsiderations received through mail, fax, or portal.
- Maintain logs of vendor refund checks and ensure appropriate routing to the accounting or payment posting team as required.
- Track recoupment letters and process refunds or initiate recoupment in accordance with established procedures.
- Mail & Documentation
- Retrieve, open, and disseminate mail received in accordance with established procedures.
- Investigate and resolve returned vendor checks in accordance with established procedures.
- Fold, stuff, and post vendor paperwork.
- Print and mail specific claims to correct payer.
- Identify and report misdirected claims or correspondence for appropriate routing.
- File maintenance, to include boxing up files to be sent to a secure storage area.
- Scan and index claim-related correspondence into the claims system or designated shared drive.
- Assist with preparation of claim documentation for internal audits or health plan audits.
- Assist in maintaining departmental logs and tracking spreadsheets used for operational reporting.
- Perform other duties as assigned to support the efficient functioning of the claims department.
Experience
- 1 years of medical administrative experience in a physician office or other medical facility setting
- Attention to detail
- Experience with claims adjudication software (EZ-Cap preferred, but not required)
Education
- High School Diploma/GED
Knowledge, Skills & Abilities
- Working knowledge of Microsoft Office and Teams.
- Maintain strict confidentiality of protected health information (PHI) in accordance with HIPAA regulations and organizational policies.
Work Hours, Travel Requirements
- Monday – Friday, 8:00 a.m. – 5:00 p.m., and as needed to complete projects.
- Travel to administration office may be necessary.
Working Conditions & Physical Requirements
- This job operates in an office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, scanners, filing cabinets and fax machines.
- The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. This is largely a sedentary role; however, some filing is required. This would require the ability to lift files, lift boxes of files, open filing cabinets and bend or stand on a stool as necessary. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
Please note this job description is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities that are required of the employee for this job. Job responsibilities, location, work hours, etc., may change at any time with or without notice.