Provider Complaint Analyst

About Texas Children's Hospital

Summary:

We are searching for a Provider Complaint Analyst -- someone who works well in a fast-paced setting. In this position, you will investigate, analyze, and resolve provider complaints and issues. Develop and maintain positive relationships externally and interdepartmentally, and support Texas Children's Health Plan provider network. Responsible for provider education, researching claims, reviewing provider records, researching potential configuration issues, problem-solving and analysis, and coordinating provider issue investigations.

Think you’ve got what it takes

Job Duties & Responsibilities
•    Research and resolve provider complaints and issues thoroughly, accurately, and timely
•    Partner with Health Plan business partners, as needed, to research and resolve provider issues. Ensure that provider records and payer systems are updated correctly and that claims are processed timely and accurately
•    Analyze and validate provider information and issue resolution from multiple sources, such as TMHP, Master Provider File, provider contracts, etc.
•    Analyze trends, and variances, and assess the impact of changes to support business decisions
•    Address provider issues submitted via the Provider Complaints Department communication email boxes, Macess service forms, as well as other Ad hoc assignments
•    Assures compliance with all regulatory and departmental requirements for provider complaints
•    Review and respond to inquiries within established timeframes from both internal and external stakeholders; ensuring that Provider Complaints Department meets its service level agreements
•    Establish and maintain positive relationships with providers and internal partners
•    Coordinate written and verbal responses to provider complaints/inquiries received or assigned
•    Educate providers on health plan policies and procedures, online tools, Medicaid guidelines, claims issues, authorization issues, contracting concerns, etc.
•    Ensure that responses to inquiries meet Health Plan and department policies and procedures, as well as State guidelines
•    Drive process improvement and provide education to the organization
•    Identify the root cause of provider issues, recommend solutions, and drive permanent resolution
•    Create documentation, such as training materials, and educate the organization and provider network on Health Plan updates identified through the provider issue resolution process

Skills & Requirements
•    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
•    Required H.S. Diploma or GED with a preferred Bachelor's Degree
•    Required 2 years of Medicaid managed care, provider reimbursement and analysis, provider contracting and records, health plan operations, health plan payer systems/applications, claims research and preferred 1-year provider relations and complaints resolution experience
•    A Bachelor's degree may substitute for the required work experience