Sr. Eligibility Specialist

Position: Sr. Eligibility Specialist

Job ID: 401068

Location: US-TX-Houston

Department: Business Operations - Admin

Talent Area: Administrative Support

Full/Part Time: Full time

Regular/Temporary: Regular

Shift: 8a-5p

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 Senior Eligibility Specialist-- someone who works well in a fast-paced setting. In this position, you will validate that member eligibility data is accurate and complete by auditing, reconciling, and updating the data in the claims processing system and the Pharmacy System. Research and resolve member eligibility issues completely, correctly, and timely. Provide a comprehensive and timely response to member eligibility inquiries from internal and external stakeholders. 

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. Preferred Bachelor's Degree
•    4 years Previous experience working at or with an HMO or MCO organization
•    A Bachelor's degree may substitute for 2 years of required work experience

Job Duties & Responsibilities
•    Ensure that the Enrollment of all Members is timely and accurate
•    Ensure member eligibility data is processed in accordance with Health Plan and department policies and procedures, as well as State guidelines and requirements
•    Utilize member eligibility data provided by the State in daily and monthly files (834, Capitation, and Capitation Adjustment)
•    Generate reporting for Leadership to reflect the accuracy of all member’s enrollment
•    Review discrepancies reporting for correctness, and assign work to the team as needed
•    Validate New Member Packets, ID Card Process, Deceased Members Process, and Out of Area Members for accuracy and adhere to HHSC regulatory requirements
•    Responsible for resolving complex eligibility inquiries from within the Health Plan and directly with the State
•    Communicate with the State, as needed, to assist in researching issues and resolving them
•    Request ad hoc reports from IS as needed to support any inbound inquiries and validate the IS reporting for accuracy.
•    Works in partnership with IT on testing and implementation of new files and/or file changes, as needed.
•    Monitor the Eligibility Group mailbox, and maintain oversight for timeliness and accuracy of responses, ensuring that the department is within the agreed-upon SLAs.
•    Review the monthly reconciliation report for discrepancies and assign it to the team.
•    Collaborate with IS on any additional reporting that may be needed to support the reconciliation Engage with Finance, the PBM, or the State as needed to address any discrepancies identified during the reconciliation process.

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