Claims Overpayment Spec - PCHP

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

The Claims Overpayment Specialist is responsible for reviewing, investigating, and resolving healthcare claim overpayments. This role ensures compliance with federal and state regulations while minimizing financial discrepancies.

Minimum Specifications

Education

• High school diploma or equivalent required.

Experience

• Two (2) years of experience in healthcare claims processing or auditing, with a focus on overpayments and recoveries is required.

• Familiarity with claims adjudication processes and QNXT system knowledge preferred.

• Understanding of Texas Medicaid, TMHP guidelines, and payer-specific overpayment policies is a plus.

Skills or Special Abilities

• Strong ability to analyze claims data to identify and resolve overpayments.

• High level of accuracy in reviewing claims for overpayment discrepancies.

• Proficient in investigating root causes of overpayments and implementing corrective actions.

• Effective verbal and written communication skills to collaborate with internal teams and external providers.

• Familiarity with claims processing systems like QNXT and advanced Microsoft Excel skills.

• Understanding of claims overpayment guidelines, including federal, state, and Medicaid-specific requirements.

• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, and the Uniform Managed Care Manual.

Responsibilities

Operations:

• Collaborate with internal and external stakeholders to recover overpayments in a timely

and compliant manner and implement process improvements to prevent future

occurrences.

• Partner with claims processors, configuration teams, and auditors to resolve overpayment discrepancies and prevent recurrence.

• Communicate with providers to explain overpayment findings and coordinate repayment efforts.

• Participate in discussions to enhance claims adjudication and overpayment prevention

workflows.

• Generate reports to track overpayment trends, recovery efforts, and compliance metrics.

Data Analysis and Documentation

• Review and analyze claims data to identify overpayments based on provider contracts,

benefit policies, and fee schedules.

• Document all overpayment findings and recovery efforts in the claims system.

• Identify patterns and trends in overpayment data to recommend process changes that

improve accuracy and efficiency.

Regulatory:

• Ensure all overpayment activities adhere to federal, state, and organizational policies,

including TMHP guidelines.

• Ensure work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

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.

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.

• 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

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.