BaylorScott & White Health

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Claim Examiner I Health Plan

at BaylorScott & White Health

Posted: 2/28/2019
Job Reference #: 18016372
Keywords: health

Job Description

The Claim Examiner I for Baylor Scott and White Health (BSWH) isresponsible for claims processing, research and adjudication to correctly applybenefit determinations on routine uncomplicated medical claims (CMS 1500 andUB04) and Rx claims in accordance with claim processing guidelines.


In addition, the Claim Examiner I for BSWH has the followingresponsibilities:

§ Processes and adjusts uncomplicatedprofessional and facility and Rxclaims according to claims processing guidelines

§ Pends claims as directed bydepartmental policies and procedures, follows up for resolution and processpended claims immediately following a benefit / payment determination

§ Works claims inventory from assignedqueues to ensure all claims process within established turnaround time asdirected by department policy and procedures

§ Reviews all output reports to ensureaccurate benefit and rider determinations

§ Completes reports to ensure promptpayment of claims

§ Coordinates win-scanning of claimsrelated documents into members MACESS folder

§ Identifies and review problemssystematic or procedural with Supervisor for timely follow-up and correction

§ Consistently meet /exceed productivitystandards and accuracy standards for payment, procedural and financial

§ Performs follow-up and takes allnecessary actions required to resolve all errors and findings assessed by theQuality Review Team

§ Performs task individually and as partof an assigned team

§ Maintains confidentiality regardingrules around HIPPA guidelines

§ May be required to work in excess ofregular scheduled hours

§ Focuses on achieving departmental andorganizations objectives

§ Complies with company policies andprocedures, which includes punctuality as they relate to work time, lunch, andbreak period


The ideal candidate will possess the following knowledge,skills, and abilities:

§ Medical claims processing stronglypreferred

§ Medical terminology, CPT, HCPCS, ICD9,ICD10, and coding preferred

§ Demonstrates effective data entryskills; ability to navigate within a computer / systems-without assistance

§ Experience in a windows-based computerenvironment

§ Excellent verbal and writtencommunication skills

§ Excellent attention to detail

§ Excellent analytical and problemsolving skills

§ Ability to prioritize and work withintime frames to accomplish tasks

§ Excellent organizational skills

§ Location/Facility – Health Plan Temple Texas 

For more information onthe facility, please click our Locations link.

§  Specialty/Department/Practice– Claims 

§  Shift/Schedule – Full Time Days 

§  Benefits– Our competitive benefits package includes*:

ü  Immediate eligibility for health and welfare benefits

ü  401(k) savings plan with dollar-for-dollar match up to 5%

ü  Tuition Reimbursement

ü  PTO accrual beginning Day 1

*Note:Benefits may vary based upon position type and/or level.


BaylorScott & White Health (BSWH)  is the largest not-for-profit health caresystem in Texas and one of the largest in the United States.  With a commitment to and a track record ofinnovation, collaboration, integrity and compassion for the patient, BSWHstands to be one of the nation's exemplary health care organizations.  Our mission is to serve all people by providing personalizedhealth and wellness through exemplary care, education and research as aChristian ministry of healing. Joining our team is not just accepting a job,it's accepting a calling!


H.S.Diploma/GED Equivalent