Complaint Resolution Specialist - Member Services - The Health Plan

Position: Complaint Resolution Specialist - Member Services - The Health Plan

Job ID: 159910

Location: US-TX-Houston

Department: Member Services Admin

Talent Area: Administrative Support

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a -5p Monday - Friday

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.


We are searching for a Complaint Resolution Specialist - someone who works well in a fast-paced managed care setting. In this position, you’ll investigate and resolve member and provider complaints about claim issues.  You will be responsible in coordinating member complaint investigations, resolutions about non-claim issues and coordinate adverse determination appeals. 


Think you’ve got what it takes?

Responsibilities :

Job Duties & Responsibilities: 

  • Coordinate investigations and resolutions for complaints and appeals related to claim and non-issues that are received internally
  • Forward cases to appropriate department/staff according to subject matter when appropriate and generate acknowledgment letters within 5 business days of receiving complaint
  • Serves as liaison with other departments to facilitate member and providers claim complaint closures
  • Coordinate investigations and resolutions for complaints and appeals related to claim and non-issues that are received
  • Coordinate Fair Hearings for Adverse Determination Appeals
  • Assist in all required projects as directed to meet department objectives
  • Works on projects as assigned to prepare for external and internal reviews
  • Performs other tasks as assigned by management to meet department objectives
  • Maintains current knowledge of regulatory requirements relative to complaints and appeals


Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s, unless approved for a medical or religious exemption.



  • High school diploma/ GED
  • A minimum of two (2) years of managed care experience in the HMO, IPA or Medical Group setting
  • Knowledge of managed care, preferably member services
  • Knowledge of quality and claims processing

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