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Administrative Support
Eligibility Specialist
Houston, TX, US
We are searching for an Eligibility Specialist — someone who works well in a fast-paced setting. In this position, you will Ensure that member eligibility data is accurate and complete by auditing, validating, reconciling, and updating the data in the claims processing system. Provide a comprehensive and timely response to member eligibility inquiries from internal and external stakeholders.
Think you’ve got what it takes?
Job Duties & Responsibilities
• Validate and reconcile member eligibility data in the claims processing system after each daily and monthly file load to ensure it matches the data received from the State
• Manually update member eligibility data in the claims processing system using multiple sources for reference, including applications, databases, and reports
• Ensure member eligibility data is processed in accordance with Health Plan and department policies and procedures, as well as State guidelines and requirements
• Review member eligibility data provided by the State in daily and monthly files (834, Capitation, and Capitation Adjustment)
• Meet established performance/productivity and quality metrics for timely and accurate member eligibility
• Collaborate with Health Plan business partners, as needed, to research and resolve member eligibility issues to ensure that members have access to care and claims are processed timely and accurately
• Address member eligibility issues submitted via the Eligibility group email boxes and Macess service forms, as well as reports submitted via a secure FTP site
• Appropriately escalate substantial member eligibility issues to management
• Review and respond to member eligibility inquiries within established timeframes from both internal and external stakeholders; thereby, ensuring that the TCHP Business Operations Department meets its service level agreements (SLAs)
• Review inquiries from the State with the appropriate Health Plan leadership and/or business partners, as needed, prior to responding
• Complete inquiries submitted via the Eligibility group email boxes and Macess service forms
• Ensure that responses to inquiries meet Health Plan and department policies and procedures, as well as State guidelines and requirements
Skills & Requirements
• High School Diploma Or GED Required
• Bachelor's Degree Preferred
• 2 Years Previous Experience Working At Or With An HMO Or MCO Organization Required
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.
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.
