Claims Adjudicator - Managed Care Medicaid Payor

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 Medicaid 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. This is a Hybrid role with some in-office meetings required.

Minimum Specifications

Education

• High school diploma or equivalent required.

Experience

Responsibilities

Operations

Quality

Regulatory

Professional Accountability

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.