Medical Claims/Benefits Specialist

Position: Medical Claims/Benefits Specialist

Job ID: 162546

Location: US-TX-Houston

Department: Claims - Training/Specialists

Talent Area: Administrative Support

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

The Texas Children’s Hospital system is the largest pediatric integrated care system and is an industry leader in pediatric population health.    Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children and pregnant women.   We are an Integrated Community System providing holistic care that empowers families to live healthier lives.      Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.  Currently, the Health Plan serves more than 450,000 members across three state territories (Harris, Jefferson, North East), who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals.     To join our community of 14,000 dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at  At Texas Children’s Hospital, diversity, equity, and inclusion are at the core of our values and mission for the women and children that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization.   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 Claims /Benefits Specialist -- someone who works well in a fast-paced setting. In this position, you will investigate and accurately process claim appeals within the regulatory requirements mandated by the State of Texas.


Think you’ve got what it takes?

Responsibilities :

  • Process Specialists Adjustments, Replacements, Refunds, and Appeals Queues, at 98% average, within 30 days of receipt
  • Provide effective, timely investigations and follow-up on all internal customer requests and Special Projects
  • Identify and communicate to team, leadership, and other departments (if applicable), trends related to appeals processing not yet addressed in a desk level procedure or identified by another team member
  • Analyzes potential system configuration setup issues when trending appeals to determine if modifications must be made to increase the automation of the adjudication flow
  • Evaluates the appropriateness of code bundling, un-bundling, and addition of modifiers by provider to determine if higher level of payment is warranted or if provider is upcoding
  • Process and coordinate claims identified by the Fraud, Waste & Abuse (FWA) department for retraction and/or reprocessing
  • Process all claims for providers flagged by the Office of Inspector General for prepayment review within 30 days of receipt


  • 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 or GED required
  • 3 years claims processing experience required
  • A bachelor’s degree may substitute for the required experience

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