Eligibility Specialist Jobs

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. You will provide a comprehensive and timely response to member eligibility inquiries from internal and external stakeholders.

Skills & Requirements

• Being fully vaccinated against COVID-19 is required for all employees unless approved for a medical or religious exemption
• 2 years previous experience working at or with an HMO or MCO organization required
• High school diploma or GED required
• Bachelor's degree preferred

A bachelor's degree may substitute for the years of required work experience

Job Duties & Responsibilities

• 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
• Research and resolve member eligibility issues thoroughly, timely, and accurately
• Ensure member eligibility data is processed in accordance with Health Plan and department policies and procedures, as well as State guidelines and requirements
• Review and respond to member eligibility inquiries within established timeframes from both internal and external stakeholdersFounded 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.
• Manually update member eligibility data in the claims processing system using multiple sources for reference, including applications, databases, and reports
• Respond timely to member eligibility inquiries from internal and external stakeholders
• 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

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.