Job Description
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.
Must have two (2) years of healthcare claims adjudication experience, pursuing claims overpayments to ensure recovery from providers, participants, or other responsible parties. Primary Purpose The Parkland Community Health Plan (PCHP) Recovery Analyst is responsible for identifying, validating, pursuing, and recovering claim overpayments paid by PCHP. This role ensures timely and accurate processing of overpayment recoveries while maintaining compliance with Texas Medicaid policies, PCHP guidelines, and other regulatory requirements. Minimum Specifications Education - Bachelor's degree in healthcare administration, business, finance, or a related field required.
Experience - Two (2) years of experience in payment integrity and healthcare claims adjudication.
- Experience working with TMHP claims and Medicaid regulatory requirements preferred.
- Experience in collections strongly desired.
- Expertise in the QNXT platform preferred.
Equivalent Education and/or Experience - May have an equivalent combination of education and/or experience in lieu of specific education and/or experience as stated above.
Skills or Special Abilities - 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.
- Strong understanding of claims adjudication processes, benefit structures, and provider contracts.
- Familiarity with medical claims, COB, and third-party liability cases.
- Ability to identify and resolve claim discrepancies effectively and efficiently.
- Comfortable in a fast-paced environment with the ability to meet productivity and quality goals.
- Familiarity with the claim's life cycle, including submission, processing, adjudication, and payment processes.
- 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 - Identify, validate, and pursue claims overpayments to ensure recovery from providers, participants, or other responsible parties in compliance with Texas Medicaid and PCHP policies.
- Ensure timely collection efforts by sending provider recoupments, recovery letters, and follow-up notices for outstanding overpayments.
- Record solicited and unsolicited overpayments in tracking systems and adjust claims as refunds are received.
- Track and process recoupments for claims overpayments, ensuring accurate documentation and follow-through.
- Investigate claims related to third-party liability cases, including Texas Medicaid subrogation, auto accidents, workers' compensation, and other liability claims, ensuring proper coordination of benefits.
- Respond to inquiries and process information requests regarding overpayments from internal departments, providers, participants, attorneys, and other third-party representatives.
- Maintain accurate system records and notes, ensuring proper documentation of communications, refunds, claim adjustments, and case resolutions.
- Prepare reports and track overpayment recovery trends to support process improvement and compliance initiatives.
- Collaborate with outsourced vendors and supports their efforts in the identification of overpayments.
- Collaborates with internal teams, providers, and external stakeholders to support efficient claims reconciliation and cost recovery efforts.
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.
- Support ongoing process improvements to minimize claim payment errors and enhance recovery operations.
- Collaborate with internal teams (Claims, Finance, Compliance, and vendor partners) to enhance efficiency and reduce payment discrepancies.
Regulatory - Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.
- Ensure compliance with Texas Medicaid, federal, state, and PCHP-specific guidelines related to overpayment recovery and third-party liability claims.
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 - 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.
- 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.
- 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.
Job Tags
Contract work, Work at office,