Responsible for routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration. May include physician, outpatient, inpatient, facility, long term services and supports, etc.
High School Diploma or GED.
5-8 years medical claims processing experience, claim adjudication, and coordination of benefit plans.
2-3 years Medicaid/ Medicare audit experience.
Demonstrated ability to analyze benefit issues, claim pricing methodology (Fee Schedule, DRG etc.) and an advanced knowledge of Medicaid claim processing procedures and guidelines.
Advanced knowledge of insurance industry and medical terminology.
Proficiency with Microsoft Office including Outlook, Word, Excel and Access.
Excellent Customer Service Skills with ability to explain complicated benefit issues.
Previous Project Management or Project Coordination experience.
Strong communication skills, both written and verbal.
Strong business acumen with the ability to build and maintain relationships.
Strong analytical skills, with the ability to identify a root cause and come up with solid resolution.
Internal Number: 44053
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.