Provider Complaint Analyst

Position: Provider Complaint Analyst

Job ID: 400729

Location: US-TX-Houston

Department: Provider Relations Response

Talent Area: Professional - Non-Clinical

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 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

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