Eligibility Specialist

Texas Children's Hospital; Bellaire (TX); On-site; USD 48,000 - 66,000; Full time

Job summary

Texas Children's Hospital is seeking an Eligibility Specialist to ensure the accuracy of member eligibility data in the claims system and to respond to inquiries from internal and external stakeholders. You will audit, validate, and reconcile daily/monthly files, update records from multiple sources, and ensure compliance with state guidelines.

You will work with Health Plan partners to resolve issues, meet SLAs, and escalate complex cases as needed, ensuring timely access to care for members

Qualifications

• High School Diploma or GED Required (as a baseline)
• Bachelor's Degree Preferred
• 2 Years Previous Experience Working at or with an HMO Or MCO Organization Required

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 escalated 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

Education

Bachelor's Degree Preferred

Job description

Job Description

At Texas Children's Hospital, our mission starts with our people. Guided by our HEART values—Humility, Excellence, Accountability, Respect, and Trust,we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. As an Eligibility Specialist, 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.

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 escalated 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

Qualifications

• 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 Us

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.

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.