Eligibility Specialist

Texas Children's Hospital•Bellaire, TX

22h

About The Position

At Texas Children’s Hospital, the mission is supported by a workplace guided by the HEART values: Humility, Excellence, Accountability, Respect, and Trust. The Eligibility Specialist ensures member eligibility data is accurate and complete by auditing, validating, reconciling, and updating information in the claims processing system. The role also provides comprehensive and timely responses to member eligibility inquiries from internal and external stakeholders. Texas Children’s Health Plan provides STAR/Medicaid and CHIP coverage to pregnant women, teens, children, and adults in Houston and surrounding areas. The Health Plan serves more than 375,000 members through a network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals.

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 multiple reference sources, including 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 so members can access care and claims are processed accurately and on time.
Address eligibility issues submitted through Eligibility group email boxes and Macess service forms, as well as reports submitted 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 support departmental 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.