Eligibility Specialist

Texas Children's Medical Center•Bellaire, TX

About The Position

At Texas Children’s Hospital, the mission starts with its people. Guided by the HEART values—Humility, Excellence, Accountability, Respect, and Trust—the organization strives to create a workplace where teammates feel valued, supported, and empowered. The Eligibility Specialist ensures member eligibility data is accurate and complete by auditing, validating, reconciling, and updating data in the claims processing system. The role also provides comprehensive and timely responses to member eligibility inquiries from internal and external stakeholders.

Requirements

High school diploma or GED required.
Two years of previous experience working at or with an HMO or MCO organization required.

Nice To Haves

Bachelor’s degree preferred.

Responsibilities

Validate and reconcile member eligibility data in the claims processing system after daily and monthly file loads to ensure it matches data received from the State.
Manually update member eligibility data in the claims processing system using reference sources such as applications, databases, and reports.
Ensure eligibility data is processed according to Health Plan and department policies and procedures, as well as State guidelines and requirements.
Review State-provided member eligibility data in daily and monthly files, including 834, Capitation, and Capitation Adjustment files.
Meet established performance, productivity, and quality metrics for timely and accurate member eligibility processing.
Collaborate with Health Plan business partners to research and resolve eligibility issues, supporting member access to care and timely, accurate claims processing.
Address eligibility issues submitted through group email boxes, Macess service forms, and reports received through a secure FTP site.
Escalate substantial member eligibility issues to management as appropriate.
Review and respond to eligibility inquiries from internal and external stakeholders within established timeframes to help the TCHP Business Operations Department meet its service-level agreements.
Review State inquiries with appropriate Health Plan leadership and/or business partners before responding, as needed.
Complete inquiries submitted through Eligibility group email boxes and Macess service forms.
Ensure inquiry responses comply with Health Plan and department policies and procedures, as well as State guidelines and requirements.