We are looking for an Appeal Specialist- someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will be instrumental in providing education and assisting members to understand their benefits related to the Appeals, External Medical Review and/or Fair Hearing Process. Acts as the first point of contact for assistance or information via oral and/or written communication throughout the resolution process.
Think you’ve got what it takes?
Skills & Requirements
- H.S. Diploma or GED is required
- CHW - Community Health Worker licensed by Texas Department of State Health Services preferred
- 4 years Fundamental Utilization Management experience required
- 2 years Direct experience with UM Prior Authorizations, Appeals, Fair Hearing and External Medical Review preferred
Job Duties & Responsibilities
- Provides member support and advocacy.
- Supports Appeal, External Medical Review (EMR), and State Fair Hearing process.
- Participates in Utilization Management Process.
- Participates in quality initiatives.
- Educates Members about their rights and responsibilities, which includes the complaints and appeals, External Medical Review and State Fair Hearing process.
- Advocates for members during appeals, and External Medical Review and State Fair Hearings; complies all necessary information to ensure appropriate Member representation.
About Texas Children’s
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 texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.
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.